F>WEBEM-TED     BY 

J.  B.  L1PP1NCOTT  CO. 
G.  s.  QEIORGE: 


SUTTER 
OOAST    REPRESENTATIV 


THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


GIFT  OF 


SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


4,'587 

SURGERY 

OF  THE 

VASCULAR  SYSTEM 


BY 

BERTRAM  M.  B_ERNHEIM,  A.B.,  M.D. 

INSTRUCTOR  IN  SURGERY,  THE  JOHNS  HOPKINS  UNIVERSITY,  BALTIMORE,    MD. 


WITH  S3  ILLUSTRATIONS  IN  TEXT 


PHILADELPHIA  &  LONDON 
J.  B.  LIPPINCOTT  COMPANY 


COPTRIGHT,    1913 
BY   J.    B.    LIPPINCOTT   COMPANY 


ELECTROTrPED   AND   PRINTED   BY  J.    B.   LIPPINCOTT   COMPANY 
AT   THE   WASHINGTON   SQUARE   PRESS,  PHILADELPHIA,  V.  S.  A. 


Ubntr 


If  13 


TO 

H.  M.  B. 


i 
I 


. 


o 


PREFACE 

THE  field  of  blood-vessel  surgery  offers  great  possibilities 
for  future  development,  if  this  present  early  period  of  growth 
is  not  impeded  by  attempts  on  the  part  of  unskilled  operators 
to  practise  it.  Brilliant  laboratory  results  achieved  in  this 
work  have  often  lured  the  inexperienced  to  try  their  luck, 
only  to  find  that  chance  here  plays  no  part  and  that  success 
is  measured  only  by  years  of  trial,  first  in  the  laboratory, 
then  in  the  clinic. 

This  book  is  intended  to  be  a  practical  and  suggestive  aid 
to  the  surgeons  interested  in  this  branch  of  work;  in  it  the 
various  methods  employed  in  the  field  of  vascular  surgery 
will  be  explained  as  simply  as  possible,  a  fundamental  knowl- 
edge of  the  condition  in  hand  being  always  taken  for  granted. 
For  example,  in  considering  the  subject  of  aneurisms,  the 
anatomical,  pathological,  and  etiological  sides,  already  de- 
scribed by  other,  more  authoritative,  writers,  will  be  omitted ; 
and  in  the  descriptions  of  operative  procedures  where  sev- 
eral methods  have  been  devised,  the  one  or  two  best  and 
most  employed  have  been  selected  for  detailed  exposition. 
This  course  has  been  pursued  not  to  spare  the  writer 
wearying  labor,  but  to  present  directly  to  the  reader  a 
text  unhampered  by  preliminary  review  and  multiplication 
of  detail. 

It  is  a  pleasure  to  gratefully  acknowledge  the  interest 
which  Dr.  ~W.  S.  Halsted,  himself  one  of  the  pioneers  in 
modern  vascular  surgery,  has  shown  in  my  work;  to  thank 
Dr.  John  M.  T.  Finney  for  his  sympathetic  help  and  the 
clinical  opportunities  which  he  and  Dr.  J.  C.  Bloodgood  have 
afforded  me;  to  acknowledge  my  large  debt  to  Dr.  Harvey 
Gushing,  during  whose  direction  of  the  Hunterian  Lab- 


vi  PREFACE 

oratory  for  Experimental  Medicine  my  researcli  work  was 
performed. 

The  enthusiastic  co-operation  of  Mr.  .James  F.  Didusdi. 
who,  under  the  supervision  of  Mr.  Max  Broedel,  furnished  the 
illustrations  for  this  book,  has  been  much  appreciated. 

BERTRAM  M.  BERNHEIM. 
BALTIMORE,  1913. 


BRIEF  HISTORICAL  NOTE 

A  GRADUAL  process  of  evolution,  similar  to  that  which 
took  place  in  intestinal  and  other  branches  of  surgery,  has 
given  rise  to  the  present-day  technic  in  blood-vessel  work. 
The  names  of  Eck,  Gliick,  Hunter,  Jassinowsky,  Doerfler. 
Murphy,  Jaboulay,  v.  Hirsch,  Payr,  Hophner,  and  others  will 
always  be  closely  linked  with  this  development,  which,  be- 
cause no  consistently  successful  method  of  suturing  vessels 
could  be  devised  until  a  perfect  asepsis  had  been  achieved, 
marks  a  real  triumph  in  modern  medicine.  After  the  attain- 
ment of  this  most  important  goal,  perfect  asepsis,  a  method 
simpler  than  all  those  previously  suggested,  became  the 
method  of  choice,  and  the  general  technic  developed  by  Carrel 
in  working  up  his  simple  end-to-end  suture  (1905)  formed 
the  basis  for  all  future  endeavor  in  this  field. 

Inspired  to  renewed  efforts  by  the  achievements  of  Carrel, 
and  founding  their  work  upon  his  tenets,  workers  in  clinics 
the  world  over  have  carried  out  many  brilliant  researches. 
Numerous  modifications  of  his  suture  method  have  been  sug- 
gested, for  example,  those  of  Payr,  Dorrance,  and  others, 
and  to  a  certain  extent  have  been  adopted,  but  all  have 
lacked  that  perfect  simplicity  so  characteristic  of  the  Carrel 
method  and  so  essential  to  success  in  vascular  surgery. 

Previous  to  the  work  of  Carrel  the  chief  interest  in  blood- 
vessel surgery  centred  about  the  treatment  of  aneurisms,  and 
the  names  of  Antyllus,  Moore,  Corradi,  Macewen,  Keen, 
Halsted,  Matas,  and  others  are  closely  connected  with  this 
branch  of  the  subject.  Now  aneurisms,  important  as  is  their 
consideration,  demand  only  part  of  our  attention — for  the 
subject  has  widened  to  include  the  repair  of  injured  blood- 
vessels, the  transplantation  of  arterial  or  venous  segments 

vii 


viii  BRIEF  HISTORICAL  NOTE 

between  the  ends  of  a  resected  vessel,  end-to-end  or  lateral 
anastomosis,  and  direct  transfusion  of  blood.  The  operation 
of  transfusion,  employed  from  authoritative  records  as  early 
as  1492  in  a  vain  attempt  to  save  the  life  of  the  then  Pope 
Innocent  VIII,  has  throughout  the  history  of  surgery  never 
been  lost  sight  of  as  a  possible  procedure,  but  has  always 
failed  of  consistent  results,  until  the  work  of  Crile,  in  our 
own  day  and  country,  put  it  upon  the  basis  of  safety  and 
practicability. 

This  brief  review  must  convey  the  forcible  impression  of 
work  only  begun,  and  I  feel  sure  that  it  will  be  the  privilege 
of  some  not  too  distant  chronicler  to  include  in  his  records 
great  progress  in  this  branch  of  our  endeavor. 


CONTENTS 

CHAPTER  I.  PAGE 

GENERAL  TECHNIC 1 

CHAPTER  II. 
TRANSFUSION 8 

CHAPTER  III. 

END-TO-END  SUTURE 28 

CHAPTER  IV. 
LATERAL  ANASTOMOSIS 37 

CHAPTER  V. 
TRANSPLANTATION  OF  A  SEGMENT  OF  VEIN  OR  ARTERY 46 

CHAPTER  VI. 
ARTERIOVENOUS  ANASTOMOSIS — REVERSAL  OF  THE  CIRCULATION 53 

CHAPTER  VII. 
VARICOSE  VEINS 61 

CHAPTER  VIII. 
SURGERY  OF  THE  HEART 64 

CHAPTER  IX. 
ANEURISMS 68 

CHAPTER  X. 
STATISTICAL  STUDY  OF  THE  TREATMENT  OF  ANEURISMS 81 


ILLUSTRATIONS 

FIG.  PAGE 

1.  Author's  ball-tipped  forceps 2 

2.  Needle  and  thread  mounted  and  ready  for  sterilization 5 

3.  Flask  containing  liquid  vaseline  and  four  mounted  needles 6 

4.  Crile  cannula 10 

5.  Drawing  vein  through  cannula 10 

6.  Cuffing  vein  back  over  the  cannula 11 

7.  Vein  cuffed  and  tied  in  groove  nearest  handle  of  the  cannula.    Artery  grasped 

by  three  mosquito  clamps 11 

8.  Artery  slipped  over  cannula  and  tied  in  the  second  groove 12 

9.  Author's  three-pronged  modification  of  Crile's  cannula 13 

10.  Elsberg's  monkey-wrench  cannula 13 

11.  Artery  "set"  in  Elsberg's  cannula;  tenacula  in  position  for  cuffing 14 

12.  Artery  everted  and  impaled  on  the  hooks.    Vein  grasped  by  mosquito  clamps  14 

13.  Cannula  slipped  into  side  of  vein  and  tied  in  position 14 

14.  Author's  two-pieced  transfusion  tube 16 

15.  Incision  in  wrist  of  donor,  showing  radial  artery  and  vense  comites 17 

16.  Radial  artery  separated  from  vena3  comites,  doubly  ligated,  and  divided.  ...  18 

17.  Cutting  oval  opening  in  side  of  radial  artery 19 

18.  Slipping  male  half  of  tube  into  the  artery 20 

19.  Tube  tied  in  place  in  the  artery 21 

20.  Female  half  of  tube  tied  in  position  in  vein  of  the  recipient 22 

21.  Tubes  invaginated  and  anastomosis  complete 23 

22.  Severed  ends  of  an  artery  showing  the  over-hang  of  adventitia 29 

23.  Drawing  adventitia  well  out  over  end  of  the  artery 29 

24.  Cutting  off  adventitia  flush  with  end  of  the  artery 30 

25.  Washing  out  vessels  with  liquid  vaseline  and  salt  solution 31 

26.  Three  stay  sutures  placed 32 

27.  Stay  sutures  tied  and  vessel  triangulated 33 

28.  Sewing  first  side  of  triangle 34 

29.  Sewing  second  side  of  triangle 34 

30.  Sewing  third  side  of  triangle 35 

31.  Suture  complete 35 

32.  Diagram  showing  method  and  principle  of  making  incision  in  vessels  in  lateral 

anastomosis.    Method  of  Bernheim  and  Stone 37 

33.  Incision  made  in  side  of  artery  and  being  made  in  side  of  vein 38 

34.  Drawing  adventitia  away  from  the  oval  opening 39 

35.  Cutting  away  the  adventitia 40 

36.  Washing  out  the  vessel  with  salt  solution  and  liquid  vaseline 41 

37.  Starting  suture  of  the  vessels 42 

38.  Posterior  row  of  sutures  being  placed 42 

39.  Posterior  row  of  sutures  completed;  anterior  row  being  placed 43 

40.  Suture  completed  and  being  tied  to  first  knot 43 

41.  Clamps  removed  from  vessels.    Proximal  ligation  of  vein 44 

xi 


xii  ILLUSTRATIONS 

42.  Washing  out  a  venous  transplant  with  liquid  vaseline  and  salt  solution 46 

43.  Cutting  adventitia  away  from  edges  of  venous  transplant 46 

44.  Measuring  venous  transplant  between  ends  of  artery 47 

45.  The  transplant  "set"  by  stay  sutures  placed  at  either  end Is 

46.  Suture  in  progress 48 

47.  Suture  complete;  vein  flaccid;  clamps  still  on  artery 49 

48.  Blood  going  through  transplant.    Vein  bulged  and  tense  from  arterial  pressure. 

Slight  irregularity  indicates  situation  of  reversed  valves 50 

49.  Valves  of  vein— diagram  showing  necessity  for  reversal  in  placing  a  venous 

transplant 51 

50.  Obliterative  endo-aneurismorrhaphy   (Matas) 71 

51.  Restorative  endo-aneurismorrhaphy  (Matas)  applied  to  sacculated  aneurisms 

with  a  single  orifice  of  communication 71 

52.  Restorative  endo-aneurismorrhaphy  (Matas).    Aneurismal  sac  closed  off  from 

parent  artery 72 

53.  A,  Halsted's  original  band  and  roller  in  the  act  of  curling  a  metal  strip  about 

an  artery;  B,  the  improved  band  roller  about  to  expel  a  band 79 


SURGERY  OF  THE  VASCULAR 
SYSTEM 

CHAPTER  I 

GENERAL  TECHNIC 

General  Considerations. — The  success  of  blood-vessel 
work,  anastomoses,  transfusions,  repair  of  injuries,  etc., 
depends  almost  entirely  on  the  avoidance  of  a  blood-clot— 
and  a  general  technic  has  been  evolved  which  if  properly 
observed  gives  most  consistent  results. 

The  wall  of  a  blood-vessel,  it  is  well  known,  is  made  up 
of  three  separate  and  distinct  layers  of  tissue, — intima,  media, 
and  adventitia — each  of  which  can  be  readily  separated  from 
its  neighbor.  Of  these  three  coats  the  adventitia,  or  outer 
layer,  is  by  far  the  most  important  to  the  surgeon  engaged  in 
vascular  work,  because,  made  up  of  a  most  delicate  network 
of  fibrous  tissue,  it  hangs  over  the  end  of  a  severed  and 
collapsed  vessel,  and  acts  as  a  sieve  for  the  smallest  drop  of 
blood  and  us  a  nucleus  for  the  formation  of  a  clot.  Its 
flaccidity  would  seem  to  render  its  removal  an  easy  matter, 
and  so  it  does ;  but  this  very  characteristic,  this  very  mobility, 
causes  still  more  of  it  to  slip  into  the  needle  hole,  and  if  great 
care  be  not  taken  it  acts  as  the  starting  point  of  a  thrombus 
in  an  otherwise  perfect  suture.  True,  the  scratched  intima  is 
an  ever-present  source  of  danger,  as  shown  in  the  classic 
work  on  "Thrombosis  and  Embolism"  -of  Welch,  but  one 
has  only  to  consult  the  works  and  writings  of  those  who 
have  done  pioneer  work  in  the  field  of  vascular  surgery  to 

realize  that  neither  the  intima  nor  the  media  is  greatly  to 

l 


2  SURGERY  OF  THE  VASCULAR  SYSTEM 

be  feared.    The  adventitia  is  the  chief  foe,  and  a  worthy  one 
at  that. 

Blunt  Instruments. — Perhaps  the  first  principle  to  be 
learned  is  that  blood-vessels  resent  being  handled  by  any 
other  than  blunt  instruments,  and  of  these  instruments  the 
fingers  are  the  most  useful  and  the  safest.  I  am  well  aware 
of  the  fact  that  this  dictum  is  diametrically  opposed  to 
present-day  teaching  regarding  surgery  in  general,  but  a 
careful  consideration  of  all  the  factors  involved  has  led  me 
to  express  this  view.  The  blood-vessel  wall  is  only  too  easily 
crushed;  it  should,  therefore,  never  be  grasped  by  a  sharp- 


Fio.  1. — Author's  ball-tipped  forceps.    Prevent  injury  to  vessel  wall,  especially  scratching  of  intima. 

pointed  or  mouse-toothed  forceps.  But  since  the  work  can  at 
times  be  facilitated  by  a  delicate  pair  of  forceps,  I  have  had 
one  constructed  which  has  a  small,  polished  metal  knob  about 
the  size  of  an  ordinary  pin-head  on  each  end.  These  knobs 
enable  one  to  grasp  the  vessel  firmly  without  doing  the 
slightest  damage  to  the  intima  (Fig.  1).  Small  branches 
should  be  utilized  to  lift  the  mother  trunk,  or  a  blunt  dissector 
can  be  gently  inserted  beneath  the  vessel,  which  can  then  be 
raised  or  put  on  the  stretch  with  impunity,  so  long  as  gentle- 
ness is  employed. 

After  a  vessel  is  thus  exposed,  and  has  once  been 
mobilized  to  a  certain  extent,  it  can  be  grasped  with  the 
thumb  and  forefinger.  At  times  it  may  be  more  convenient 
and  equally  efficacious  to  insert  a  soft  tape  (one-fourth  inch 


GENERAL  TECHNIC  3 

wide)  beneath  the  vessel  and  use  it  as  a  tractor.  Thus  an 
artery  or  vein  can  be  dissected  out  of  its  bed  without  the 
slightest  instrumental  insult. 

Salt  Solution  and  Liquid  Vaseline. — During  the  entire 
course  of  any  operation  involving  blood-vessels,  the  haemo- 
stasis  must  be  absolutely  perfect,  or  as  nearly  so  as  possible. 
All  branches,  large  and  small — capillaries  excepted — should 
be  cut  between  two  clamps  and  tied.  Despite  these  precau- 
tions, however,  there  will  always  be  a  certain  amount  of 
staining,  which  is  best  removed  with  gauze  sponges  wrung 
out  in  normal  salt  solution.  In  addition  to  this  a  stream  of 
warm  salt  solution  should  be  played  on  the  wound  at  intervals 
during  the  entire  course  of  the  operation,  especially  after 
exposure  of  the  vessels.  This  is  not  alone  for  the  purpose 
of  removing  blood  and  clot,  but  to  prevent  drying  of  the 
tissues  as  well — a,  phenomenon  that  occurs  with  striking 
rapidity  in  wounds  of  this  character,  and  one  that  is  to  be 
avoided  at  all  costs.  Indeed,  so  careful  must  we  be  in  this 
respect  that  we  have  called  to  our  aid  another  agent  better 
qualified  to  prevent  drying  than  salt  solution — liquid  vase- 
line,1 a  neutral  lubricant  that  keeps  the  tissues  soft  and 
pliable,  prevents  too  rapid  evaporation,  and  is  tolerated  by 
the  organism  in  almost  any  quantity.  The  combination  of 
salt  solution  and  liquid  vaseline,  each  judiciously  used,  keeps 
the  wound  in  a  beautiful  state  of  pliability  that  renders  all 
manipulations  much  easier  to  accomplish  and  less  liable  to 
damage  any  of  the  delicate  structures  handled. 

Handling  the  Severed  Vessel. — If  care  is  necessary  in 
handling  the  vessel  intact,  the  utmost  consideration  must  be 
exercised  in  dealing  with  it  severed.  Intima  must  not  be 
scratched,  and  yet  all  blood  and  every  vestige  of  fibrin  must 
be  scrupulously  washed  out  of  the  vessel.  Salt  solution 

1 1  use  that  made  by  Chesebrough  Manufacturing  Company  of  New  York. 


4  SURGERY  OF  THE  VASCULAR  SYSTEM 

thrown  on  and  into  the  vessel  by  a  blunt-tipped  rubber 
syringe  together  with  restrained  stripping  with  the  fingers 
works  wonders,  but  the  overhang  of  adventitia  that  occurs 
as  soon  as  the  vessel  is  cut  and  soaked  in  salt  solution  ob- 
structs the  lumen  to  such  a  degree  that  complete  cleansing 
is  impossible  until  it  has  been  removed.  This  is  accomplished 
by  grasping  it  with  the  thumb  and  forefinger,  or  a  very 
delicate  pair  of  mouse-tooth  forceps,  drawing  it  well  down 
over  the  end  of  the  vessel, — it  comes  down  with  remarkable 
ease, — and  cutting  it  off  flush  with  the  cut  edge.  Thus  freed 
from  adventitia  the  mouth  of  the  vessel  will  at  once  spring 
open,  permitting  the  insertion  directly  into  its  lumen  of  the 
perfectly  rounded  tip  of  a  medicine  dropper  filled  with  salt 
solution.  This  is  repeatedly  injected  until  all  clot  and  visible 
fibrin  are  washed  out,  whereupon  the  lumen  is  filled  with 
liquid  vaseline.  Even  before  all  clot  is  displaced  it  is  well 
to  inject  a  little  vaseline  into  the  vessel  and  around  the  field 
of  operation  in  general. 

Blood-vessel  Clam-ps. — The  blood  flow  is  at  all  times  to  be 
obstructed  by  a  rubber-shod  clamp,  of  the  variety  shown  in 
the  illustration.  The  smaller,  or  so-called  bull-dog  clamp,  is 
used  on  small  vessels  like  the  radial,  while  the  larger,  or  Crile 
clamp,  is  employed  for  vessels  of  larger  calibre.  If  the  jaws 
of  these  or  other  clamps  are  not  serrated,  they  need  not 
necessarily  be  rubber-shod,  but  I  have  always  preferred  to 
use  a  clamp  armed  with  rubber,  believing  that  it  is  safer.  At 
times  it  may  be  inconvenient  or  even  impossible  to  use  any 
clamp,  in  which  case  the  ordinary  tape  mentioned  above  when 
properly  placed  around  the  vessel  and  secured  by  an  ordinary 
haemostat,  will  act  as  a  safe  and  effectual  clamp. 

Suture  Material. — Suture  material  must  be  light  and 
delicate,  yet  strong  enough  to  withstand  any  arterial  pres- 
sure. Such  a  silk  is  the  00000  made  by  Belding  Bros.  &  Co., 
of  New  York.  It  can  be  obtained  in  either  the  white  or 
black,  is  beautifully  smooth,  withstands  sterilization  without 


GENERAL  TECHNIC  5 

loss  of  strength,  and  has  answered  every  purpose,  both  ex- 
perimental and  practical.  This  silk  is  nicely  carried  by  a 
No.  12  ground  down  needle  that  is  made  by  H.  Milward  & 
Sons.  This  needle  has  a  small  round  eye,  and  is  one  inch 
long — a  length  that  permits  of  just  the  right  amount  of 
flexibility. 

It  is  my  custom  to  use  black  thread,2  since  that  can  be 
seen  against  a  white  background  much  more 
easily  than  a  white  thread  against  a  black  back- 
ground, the  latter  being  Carrel's  method.  I 
have  noticed  absolutely  no  difference  in  the  heal- 
ing or  in  the  operative  results  following  the  use 
of  either  the  white  or  the  black  thread;  the  dye 
in  the  thread  used  for  blood-vessel  suture  is  fast 
and  almost  infinitesimal  in  amount. 

All  needles  are  threaded  and  sterilized  in  die 'and '  threTd 
liquid  vaseline  before  operation,  the  routine  ready nfor  sterm- 
being  to  thread  each  needle  with  about  twelve 
inches  of  the  black  silk,  drawing  the  ends  even  and  fixing 
each  needle  on  a  separate  piece  of  ordinary  writing  paper, 
about  one-half  inch  by  one-quarter  inch,  in  such  a  way 
that  the  doubled  thread  is  wound  around  the  needle  by 
a  figure-of-eight  (Fig.  2),  and  the  final  end  of  the  thread 
caught  by  a  slit  in  one  corner  of  the  paper.  Thus  prepared, 
four  threaded  needles  are  placed  in  a  small  flask  containing 
one  or  two  ounces  of  liquid  vaseline  (Fig.  3)  and  sterilized  in 
the  usual  way.  Just  before  operation  the  contents  of  one  or 
more  flasks,  oil  as  well  as  needles,  are  poured  into  a  dry 
sterile  medicine  glass  and  placed  on  the  instrument  table.  I 
have  made  it  a  rule  to  allow  no  one  but  myself  to  touch  these 
needles  at  operation,  and  I  leave  them  lying  in  the  oil  until 
the  time  for  actual  suture  comes,  when  I  carefully  remove 

2  The   thread   and   all    instruments   used   in   vascular   work   are   handled   by 
the  Chas.  Willms  Surgical  Instrument  Company,  of  Baltimore. 


(I 


SURGERY  OF  THE  VASCULAR  SYSTEM 


one  needle  from  its  paper  by  going  through  che  reverse  figure- 
of-eight.  One  end  is  then  shortened  to  about  two  inches,  and 
the  needle  and  thread  are  given  a  final  inspection  for  any 

defects,  such  as  small  spots  of 

rust  or  inequality  or  roughness 
in  the  silk.  If  this  examination 
is  satisfactory  the  suture  is  be- 
gun, a  similar  procedure  being 
observed  for  each  additional 
suture  that  may  be  needed. 

Rubber  gloves  are  generally 
worn  in  blood-vessel  operations 
up  to  the  point  of  actual  suture, 
though  sometimes  only  to  the 
point    where    the    washing-out 

«  process  of  the  vessels  begins. 

jjjl  Their  discard  at  this  point  is  at 

present  an  unavoidable  and  un- 
y  V4  fortunate  break  in  technic, 

V     i^.  which  I  endeavor  to  minimize 

by  a  preparation  of  the  hands 
JB  lasting  not  less  than  twenty  to 

twenty-five  minutes.     The  deli- 

Fio.  3.— Flask  containing  liquid  vaseline          nftf>v    r»f    tViA    TrmnirmlfltioTKJ    and 
and  four  mounted  needles.     Sterilized  and          CECV    OI    Hie    manipulations    dl] 

the  fineness  of  the  needles  and 

thread  necessitate  the  use  of  the  bare  hand,  and  in  order  that 
the  skin  of  the  hands  may  be  soft  and  pliable,  it  is  well  to 
wash  them  in  salt  solution  immediately  after  discarding  the 
gloves  and  then  anoint  them  thoroughly  in  the  liquid  vaseline, 
this  process  being  repeated  as  often  as  they  become  dry. 
Attention  to  these  and  many  other  details  that  experience 
alone  can  teach  is  required  to  secure  constant  results  in  this 
field  of  surgery,  but  success  will  more  than  compensate  for 
the  patience  and  energy  it  demands. 


GENERAL  TECHNIC  7 

REFERENCES 

Artus:      Jour,  de  physiol.  et  de  path.  gen..  1902,  iv,  281. 

Eernheim,  B.  M. :     The  Relation  of  the  Blood- Vessel  Wall  to  Coagulation  of  the 

Blood,  Jour.  Am.  Med.  Asso.,  July  23,  1910. 
Delezenne:     Arch,  de  Physiol.,  1897,  series  5,  i.x,  333.    Compt.  rend.  Soc.  de  biol., 

1896,  p.  782. 

Loeb,  L. :   Virchow's  Arch.  f.  path.  Anat.,  1904,  clxxv,  10. 
Morawitz,    P. :   Beitriige    zur    Kenntnis    der    Blutgerinnung,    Deutsch.    Arch.    f. 

klin.  Med.,  1904,  Ixxix. 
Sahli,   H. :    Ueber   das   Wesen   der   Haemophilie,   Ztschr.   f.   klin.   Med.,   Bd.   56, 

1905. 

Welch,  Wm. :     Thrombosis  and  Embolism.    Allbutt's  System  of  Medicine,  vol.  vii. 
Wooldridge:     Die  Gerinnung  des  Blutes,  Leipsic,  1891. 


TRANSFUSION 

TRANSFUSION,  the  most  employed  operation  in  blood-ves- 
sel surgery,  has  presented  gratifying  results,  and  in  the 
hands  of  the  careful  surgeon  is  capable  of  lasting  and  far- 
reaching  effects. 

Transfusion  means  the  giving  of  blood  by  one  individual 
to  another,  and  there  are  two  methods  by  which  it  is  accom- 
plished, (1)  direct  and  (2)  indirect.  When  the  blood-vessels 
of  one  individual  are  directly  united  with  those  of  another, 
whether  by  suture  or  cannula  method,  and  blood  flows  from 
one  to  the  other,  we  call  the  procedure  direct  transfusion; 
when  blood  is  withdrawn  from  one  individual  by  means  of  a 
needle  and  syringe  and,  after  being  defibrinated,  is  injected 
into  another  individual,  we  call  the  procedure  indirect  trmi*- 
fusion.  I  shall  deal  exclusively  with  the  direct  method,  wlm-li 
is,  at  present,  thought  by  surgeons  to  give  better  and  more 
far-reaching  results  than  the  indirect  method.  Indirect  trans- 
fusion in  selected  cases  and  handled  properly  is  also  of  great 
service. 

To  illustrate  the  use  of  this  operation  T  wish  to  state  that 
it  shows  gratifying  success  in  cases  of  hemorrhage;  for  ex- 
ample, in  those  tragic  cases  where  fresh  blood  has  been  the 
only  means  of  making  up  the  deficiency  caused  by  accident; 
in  cases  of  bleeding  from  a  gastric  ulcer;  typhoid  ulcers; 
ruptured  extra-uterine  pregnancies;  and  in  other  conditions. 
This  emergency  use  of  transfusion  in  saving  life  after  loss 
of  blood  covers  only  part  of  the  field;  transfusion  has  re- 
peatedly been  successfully  employed  to  raise  the  resistance 
of  patients  too  weak  to  withstand  the  shock  of  a  necessary 
operation.  A  case  in  point  is  that  of  a  boy  aged  seven  (pa- 
8 


TRANSFUSION  9 

tient  of  Dr.  J.  M.  T.  Finney)  who,  suffering  from  splenic 
anaemia,  had  become  so  dreadfully  exsanguinated  from  re- 
peated hemorrhages  from  the  stomach  that  his  haemoglobin 
was  too  low  to  register.  A  splenectomy  was  successfully 
accomplished  by  Dr.  Finney  during  the  course  of  a  trans- 
fusion, and  the  boy  not  only  withstood  the  operation  but  was 
in  better  condition  at  its  conclusion  than  at  the  start.  He 
made  a  stormy  but  successful  recovery,  only  to  succumb  five 
months  later  from  another  gastric  hemorrhage,  probably  the 
result  of  an  old  cesophageal  varix. 

The  anaemias — pernicious  anaemia,  leukaemia — have  not 
responded  well  to  this  operation,  but  the  number  of  reported 
cases  upon  which  this  conclusion  is  based  is  very  small.  It 
is  possible  that  in  certain  of  these  and  other  allied  anaemias 
transfusion  may  be  of  great  service. 

Therapeutically  the  outlook  is  bright ;  for  example,  trans- 
fusion is  most  auspicious  in  hemorrhage  of  the  new-born— 
melaena.  neonatorum.  The  depleted  circulation  in  such  cases 
is  not  only  restored  but  the  obscure  condition  itself  is  cured 
in  almost  all  cases.  Haemophilia,  in  general  is  another  illus- 
tration of  the  beneficent  influence  of  this  operation  and  cer- 
tain cases  of  illuminating  gas  poisoning,  as  shown  by  Crile, 
can  be  resuscitated  by  this  means.  Beneficial  results,  even  a 
certain  number  of  cures,  have  been  attained  in  pellagra  fol- 
lowing transfusion.  Cole  reports  a  number  of  apparent  cures 
and  I  have  had  one  myself.1  Shock,  that  most  dreaded  and  most 
baffling  condition  of  all  surgical  complications,  can  frequently, 
when  all  other  measures  for  its  relief  have  been  unsuccessful, 
be  overcome  by  prompt  transfusion.  Certain  of  the  toxaemias 
would  seem  to  be  amenable  to  this  form  of  treatment.  I 
have  recently  transfused  in  a  case  of  toxaemia  of  pregnancy 

1  It  is  impossible  to  say  just  how  or  why  transfusion  is  of  service  in  this 
condition.  It  hardly  seems  likely  that  it  acts  as  a  specific.  A  more  logical 
deduction  would  be  that  it  raises  the  resistance  of  the  patient  by  restoring  the 
blood  picture  more  nearly  to  normal. 


10 


SURGERY  OF  THE  VASCULAR  SYSTEM 


with  a  most  promising  outcome.  Thus  far,  only  the  borders 
of  the  field  of  transfusion  have  been  opened  up  by  pio- 
neers. It  lies  full  of  promise,  inviting  exploration. 
A  number  of  instruments  have  been  devised 
for  the  purpose  of  simplifying  transfusion,  each 
one  with  a  certain  degree  of  merit.  I  have 
selected  for  description  those  three  which  I  con- 
sidered as  easiest  to  manipulate  and  as  giving 
most  favorable  results. 

First  comes  Crile 's  cannula  (Fig.  4),  most 
widely  employed  since  it  was  the  first  clinically  successful 
instrument.  Dr.  Crile,  who  has  described  the  technic  of  its 
use  in  a  number  of  papers  and  finally  in  his  excellent  mono- 


Fio.  4.— Crile 
cannula. 


FIG.  5. — Drawing  vein  through  cannula. 

graph  "Hemorrhage  and   Transfusion"   (1909),  briefly  c\ 
plains  as  follows: 

"The  vessels  to  be  anastomosed  are  exposed  (for  details 
see  page  16)  and,  after  selection  of  a  cannula  of  size  suitable 
to  the  size  of  the  vessel,  the  end  of  the  vein  is  pulled  through 


TRANSFUSION 


11 


the  handle  end  of  the  tube  by  means  of  a  single  fine  suture 
inserted  in  its  edge  (Fig.  5),  the  needle  being  left  on  the 
suture  and  passed  through  the  cannula  ahead  of  the  vein. 
The  handle  of  the  cannula  is  then  tightly  seized  by  a  pair  of 
hsemostats,  three  mosquito  hasmostats  are  snapped  at  equi- 
distant points  on  the  end  of  the  vein,  taking  care  not  to 
have  the  tips  extend  up  into  the  lumen  more  than  is  necessary 


FIG.  6. — Cuffing  vein  back 
over  the  cannula. 


FIG.  7. — Vein  cuffed  and  tied  in  groove 
nearest  handle  of  the  cannula.  Artery 
grasped  by  three  mosquito  clamps. 


to  get  a  firm  hold.  The  end  of  the  vein  is  then  cuffed  back 
over  the  cannula  by  gentle  simultaneous  traction  on  the 
three  haemostats  (Fig.  6)  and  tied  firmly  in  place  with  a  fine 
linen  thread  in  the  groove  nearest  the  handle  (Fig.  7).  The 
cuffed  part  is  next  covered  with  sterile  vaseline,  being  careful 
not  to  get  any  into  the  open  end.  This  facilitates  slipping 
the  artery  over  the  cuff.  The  haemo stats  are  removed  from 
the  full  edge  and  the  artery  may  then  be  put  in  place. 


12  SURGERY  OF  THE  VASCULAR  SYSTEM 

"Owing  to  the  elasticity  of  the  arterial  wall,  it  usually 
shrinks  (contracts)  considerably  when  the  pressure  from 
within  is  removed,  as  it  is  at  the  free  end.  To  obviate  this 
it  may  be  necessary  to  dilate  the  end  very  gently  by  inserting 
the  closed  jaws  of  a  mosquito  clamp  covered  with  vaseline  and 
opening  them  for  a  short  distance.  The  three 
haemostats  are  applied  to  the  edges,  just  as  with 
the  vein,  and  the  artery  is  gently  drawn  over 
slipped  over  can^  the  cuffed  vein  on  the  cannula  and  tied  in  place 

nula  and  tied  in  the  .    -  „  , .  ,.      ,     .  , 

second  groove.  An-     with  another  fine  linen  suture  applied  in  the 

astomosis  complete.  .     .  /TV  o\  mi  •  A 

remaining  groove  (Fig.  8).  The  mosquito 
haemostats  are  removed,  and  finally  the  large  haemostat  which 
has  been  snapped  on  the  handle  of  the  cannula  during  all 
this  time  is  removed.  The  process  is  then  completed.  After 
the  transfusion  the  cannula  is  removed,  both  artery  and  vein 
are  ligated,  and  the  wounds  are  sutured. 

"In  making  a  cannula  anastomosis,  experience  will  show 
what  size  cannula  is  suitable  for  given  vessels.  As  large  a 
size  should  be  used  as  possible,  without  injuring  the  intima 
of  the  artery  by  stretching  it  too  much.  Usually  there  will 
be  no  difficulty  in  obtaining  a  large  vein,  but  the  artery  may 
be  very  small.  If  too  small  a  cannula  is  used,  the  volume  of 
flow  will  be  diminished.  Moreover,  too  large  a  vein  will  take 
up  too  much  room  in  the  cannula  and  the  amount  of  flow 
will  be  diminished. 

"The  exposed  vessels  should  be  kept  moist  and  warm  with 
normal  salt  solution.  Not  only  is  drying  harmful,  but  tho 
flow  is  increased  through  gradual  relaxation  of  the  arterial 
wall. 

"  Experience  has  shown  that  if  anything  goes  wrong  in 
carrying  out  this  technic,  it  is  best  to  start  again  from  the 
beginning,  and  not  to  try  to  get  around  any  of  the  details  by 
substitution." 

It  is  occasionally  quite  awkward  to  properly  "set"  the 


TRANSFUSION 


13 


necessary  ties  on  Crile's  cannula.     It  was  to  overcome  this 
difficulty  that  I  modified  his  tube  by  placing  three   small 
hooks  on  the  handle  end  of  it   (Fig.  9),  thus  avoiding  the 
necessity  of  placing  the  ties  by  having  each  vessel  in  turn 
impaled  on  the  hooks.     Otherwise  the  technic 
of  the  two  instruments  is  identically  the  same. 
The  second  cannula  is  an  ingenious  device 
of  Elsberg.     It  is  built  on  the  principle  of  a 
monkey-wrench  (Fig.  10)  which  can  be  enlarged 
or  narrowed  to  any  size  desired  by  means  of  a 
screw  at  its  end.     The  smallest  lumen  obtain- 
able is  about  equal  to  that  of  the  smallest  Crile 
cannula,  and  the  largest  greater  than  the  lumen 
of  any  radial  artery.     The  instrument  is  cone- 
shaped  at  its  tip,  a  short  distance  from  which    SSST^orift 
is  a  ridge  with  four  small  pin-points  which  are 
directed  backward.    The  lumen  of  the  cannula  at  its  base  is 
larger  than  at  the  tip.     The  construction  of  the  cannula  can 
be  easily  understood  from  the  following  description  of  the 
method  of  using  it  : 


FlG  9._Author's 


FIG.   10. — Elsberg '3  monkey-wrench  cannula. 

"The  radial  artery  of  the  donor  is  exposed  and  isolated 
in  the  usual  manner.  The  cannula,  screwed  wide  open,  is 
then  slipped  under  and  around  the  vessel.  It  is  then  screwed 
shut  until  the  two  halves  of  the  instrument  slightly  compress 
the  vessel  (Fig.  11)  /  The  artery  is  then  tied  off  about  one 
centimetre  from  the  tip  of  the  cannula.  Before  the  vessel  is 
divided,  three  small-eye  tenacula  are  passed  through  the 


14 


SURGERY  OF  THE  VASCULAR  SYSTEM 


wall  of  the  artery,  at  three  points  of  its  circumference,  a  few 
millimetres  from  the  ligature.  Small  mosquito  forceps  may 
also  be  used.  These  are  given  to  an  assistant,  who  makes 
traction  on  them  while  the  operator  cuts  the  vessel  near  the 
ligature.  The  moment  the  artery  is  cut,  the  stump  is  pulled 
back  over  the  cannula  by  means  of  the  tenacula  or  forceps, 
and  is  held  in  place  without  ligation  by  the  small  pin-points 
(Fig.  12).  There  is  no  bleeding  from  the  artery,  even  though 
no  haemostatic  clamp  has  been  applied,  because  the  cannula 
itself  acts  as  a  haemostatic  clamp.  The  vein  of  the  recipient 


FIG.  11. 


FIG.  12. 


FIG.  13. 


FIG.   11. — Artery  "set"  in  Elsberg's  rannula:  tenacula  in  position  for  cuffing. 

FIG.   12. — Artery  everted  and  impaled  on  the  hooks.     Vein  grasped  by  mosquito  clampg. 

FIG.   13. — Cannula  slipped  into  side  of  vein  and  tied  in  position.     Anastomosis  complete. 

is  then  exposed  (but  not  freed),  two  ligatures  are  passed 
around  it,  one  is  tied  peripherally  in  the  usual  manner.  A 
small  transverse  slit  is  made  in  the  vein,  the  cannula  with 
the  cuffed  artery  inserted  into  the  vein,  a  ligature  tied  around 
the  vein  and  cannula  screwed  open  (Fig.  13),  and  the  blood 
allowed  to  flow.  The  rapidity  of  the  flow  can  be  varied  as 
desired  by  the  size  to  which  the  instrument  is  screwed  or 
unscrewed,  and  the  lumen  of  the  artery  is  never  diminished. 

"It  will  be  noticed  that  the  artery  is  cuffed  instead  of 
the  vein ;  this  method  I  believe  to  be  more  correct.  The  vein 
is  the  larger  vessel  and  can  therefore  be  more  easily  tele- 
scoped over  the  artery.  The  vein  is  only  exposed,  not  freed, 
and  the  artery  is  intubated  into  it. 

"With  this  cannula  I  have  been  able  to  make  the  anasto- 
mosis in  less  than  four  minutes  after  the  artery  had  been 


TRANSFUSION  15 

isolated,  and  have  found  the  entire  procedure  a  simple  one. 
The  advantages  of  the  instrument  are  the  following: 

"  (1)  One  cannula  will  fit  any  vessel. 

"  (2)  The  cannula  is  applied  around  the  vessel  instead  of 
the  vessel  being  drawn  through  the  cannula. 

"(3)  No  ligature  of  the  cuffed  vessel  is  required. 

"(4)  The  cannula  itself  acts  as  a  haemostatic  clamp. 

11  (5)  The  cuffing  of  the  artery  is  easily  accomplished  with- 
out stripping  back  the  adventitia,  and,  therefore,  the  trau- 
matism  to  the  artery  wall  is  reduced  to  a  minimum. 

"(6)  The  vein  need  only  be  exposed,  not  dissected  out 
and  cut. 

"  (7)  As  the  cannula  is  unscrewed  the  blood  will  flow,  the 
flow  can  be  regulated  at  will,  and  the  lumen  of  the  artery  is 
not  diminished." 

I  agree  with  Elsberg,  in  general,  that  it  is  preferable  to 
cuff  the  artery  rather  than  the  vein,  and  frequently  do  prac- 
tise this  method.  However,  it  is  best  to  remember  that  in 
children  (and  even  some  adults)  the  vein  is  more  delicate 
and  smaller  than  the  adult  radial  artery,  and  to  adopt  no 
inflexible  rule  in  this  matter.  The  operator  must  be  prepared 
to  adapt  himself  to  the  exigencies  of  the  occasion. 

The  third  instrument  which  I  shall  present  is  one  of  my 
own  design.  Simple  in  construction,  large  enough  to  work  with 
comfortably,  it  requires  a  minimum  of  dissection  and  can  be 
rapidly  put  into  action.  It  is  a  two-pieced  affair  (Fig.  14), 
consisting  of  two  hollow  tubes,  each  4  cm.  long,  and  each  bulb- 
ous at  one  end  in  order  to  form  a  neck  for  a  retaining  tie, 
and  bevelled  to  facilitate  entrance  into  the  vessel;  the  other 
ends  are  tubular  and  fitted  for  invagination.  The  instrument 
was  originally  constructed  in  two  sizes  as  regards  the  bore 
of  the  smaller  ends,  but  experience  has  shown  that  either 
size  will  fit  the  vessels  of  any  individual — from  an  infant  up 
to  an  adult. 

My  reason  for  having  an  instrument  thus  constructed  in 


16  SURGERY  OF  THE  VASCULAR  SYSTEM 

two  separate  parts  was  twofold.  Firstly,  in  transfusing  an  in- 
fant, it  is  usually  difficult  to  make  the  actual  union  of  vessels 
with  a  small  instrument  like  that  of  Crile  or  Elsberg  because 
of  the  smallness  of  the  parts  and  the  delicacy  of  the  infant's 
vessels.  Paraffined  glass  tubes  answer  the  purpose  fairly 
well,  but  paraffine  is  not  always  at  hand,  nor  is  a  suitable 
glass  tube,  and,  if  it  is,  the  probabilities  are  that  it  will  be 
chipped  or  broken.  Secondly,  for  emergency  work  I  believe 
that  a  cannula  constructed  in  two  pieces,  one  of  which  can  be 
rapidly  inserted  into  the  artery  of  the  donor,  and  the  other 
into  the  vein  of  the  recipient,  by  separate  crews  of  operators, 
is  best.  Even  in  cases  where  haste  has  not  been  so  urgent, 


FIG.   14. — Author's  two-pieced  transfusion  tube. 

the  ordeal  for  the  recipient,  who  is  usually  anxious  and  in  a 
precarious  state,  can  be  materially  relieved  by  preparing  the 
donor  completely  before  bringing  the  recipient  into  the 
operating  room,  or  even  by  preparing  the  two  entirely  in 
separate  rooms,  simply  wheeling  the  stretcher  of  the  donor 
into  the  recipient's  room,  placing  them  in  apposition,  and 
invaginating  the  two  halves  of  the  cannula — a  matter  of  only 
a  few  seconds.2 

The  technic,  then,  of  a  transfusion  by  means  of  this  two- 
pieced  cannula,  as  well  as  the  management  of  transfusion  in 
general,  is  as  follows:  The  radial  artery  of  the  donor  is 
usually  united  to  one  of  the  superficial  veins  at  the  elbow  of 

•An  additional  advantage  possessed  by  these  tubes  is  that  the  vessels  of 
donor  and  recipient  do  not  come  in  contact,  there  being  a  distance  of  about  an 
inch  or  inch  and  a  half  between  them.  This  is  a  great  comfort  in  those  cases 
of  infectious  diseases — typhoid,  streptococcus,  etc.— where  every  precaution 
must  be  taken  to  protect  the  donor  against  infection. 


TRANSFUSION 


17 


the  recipient;  occasionally,  because  of  infection  at  the  elbow, 
it  becomes  necessary  to  employ  a  vein  of  the  leg,  generally 


r 


!*!.  Flexor  carpi  i  JFiVi    : 
Tendon  n. 


FIG.   15. — Incision  in  wrist  of  donor,  showing  radial  artery  and  vense  comites. 

the  internal  saphenous,  although  any  available  vein  may  be 
used.    But  no  matter  whether  it  be  arm  to  arm,  or  arm  to  leg, 
in  preparing  the  patients  let  the  watchword  be  "left  to  left, 
2 


18 


SURGERY  OF  THE  VASCULAR  SYSTEM 


right  to  rif/ht"  —  in  other  words,  the  left  radial  should  always 
be  united  to  a  vein  of  the  left  arm  or  leg  and  vice-versa;  a 
few  moments'  thought  will  show  the  anatomical  reasons  for 

this.  Other  things  being  equal, 
it  is  always  wise  to  leave  the 
choice  of  radials  to  the  donor, 
but  where  he  (or  she)  has  no 
choice,  it  is  my  rule  to  utilize 
the  left  radial,  if  the  patient 
be  right  handed  and  both 
radials  are  of  the  same  size 
(which  by  the  way  is  not 
always  the  case),  his  right  if 
he  be  left  handed.  Thus  the 
donor  will  be  incapacitated  as 
little  as  possible  during  the 
healing  of  his  wound — a  detail. 
perhaps,  but  one  that  ought  to 
be  considered. 

Time  will  be  saved  if  the 
radial  is  dissected  out  as  follows,  novocain  (0.5  per  cent.) 
being  the  anaesthetic  of  choice:  (1)  expose  the  artery  with 
its  accompanying  veins  for  a  distance  of  about  two  inches 
(Fig.  15),  (2)  free  the  artery  from  the  veins  and  tie  off 
all  branches  doubly  with  very  fine  silk,  cutting  between  the 
ties;  (3)  tie  off  the  artery  doubly  at  the  distal  end  of  the 
wound  and  cut  between  ties,  thus  allowing  about  one  and 
one-half  inches  of  the  vessel  to  lie  free  in  the  wound  (Fig. 
16) ;  (4)  tie  off  all  bleeding  points  in  the  wound,  and  keep 
a  constant  stream  of  warm  salt  solution  flowing  over  the 
artery,  all  sponging  being  done  with  gauze  moistened  in 
the  same  solution;  (5)  place  a  bull-dog  clamp  on  the  vessel 
at  the  proximal  end  of  the  wound. 

Up  to  this  point  the  technic  is  the  same  no  matter  which 
method   of  anastomosis   is  to  be   used.     If  my   two-pieced 


FIG.  16. — Radial  artery  separated  from  venae 
comites,  doubly  ligated,  and  divided. 


TRANSFUSION 


19 


cannula  is  to  be  employed,  a  small  cut  is  now  made  in  the 
upper  side  of  the  artery  with  a  fine  pair  of  scissors,  the  open- 
ing being  made  at  right  angles  to  the  course  of  the  vessel 
and  about  half  its  width  (Fig.  17).  Next,  every  visible  trace 
of  blood  is  immediately  washed  out  with  warm  salt  solution 
and  liquid  vaseline,  the  latter  being  injected  into  the  lumen 


FIG.   17. — Cutting  oval  opening  in,  side  of  radial  artery. 

of  the  vessel  with  a  medicine  dropper  at  frequent  intervals 
during  the  washing  process.  It  keeps  the  vessel  soft  and 
pliable,  and  prevents  too  rapid  evaporation  and  consequent 
drying.  Any  little  bit  of  adventitia  that  may  get  into  the 
opening  should  be  carefully  pushed  away  or  cut  off. 

The  vessel  having  been  carefully  prepared,  the  bevelled 
end  of  the  male  half  of  the  tube  is  inserted  into  the  artery 
(Fig.  18)  and  held  there  by  a  tie  thrown  around  its  neck 


20  SURGERY  OF  THE  VASCULAR  SYSTEM 

(Fig.  19).  Liquid  vaseline  is  now  again  injected  into  the 
vessel  through  the  tube,  and  the  whole  thing  wrapped  in  salt- 
solution  gauze  to  await  the  completion  of  a  similar  prepara- 
tion of  the  vein  of  the  recipient.  It  is  hardly  necessary  to 
dissect  out  more  than  one  inch  of  the  vein,  and,  as  this  is 
always  quite  superficial,  the  time  required  for  the  whole 


Fio.  18.— Slipping 


jbe  into  the  artery. 


procedure  of  dissection,  cleansing,  and  insertion  of  the 
female  half  of  the  tube  (Fig.  20)  amounts  to  hardly  more 
than  five  minutes. 

When  both  patients  have  been  prepared,  their  stretchers 
are  brought  into  apposition  and  the  two  arms  are  placed  on 
a  table  about  one  foot  broad.  With  a  little  manipulation  the 
wrist  of  the  donor  is  brought  into  such  proximity  to  the 


TRANSFUSION 


elbow  of  the  recipient  that  the  tubes  can  be  invaginated 
(Fig.  21)  to  the  proper  degree.  When  this  is  accomplished, 
a  steady  stream  of  warm  salt  solution  is  started  flowing  over 
the  artery,  tubes,  and  vein,  and  the 
bull-dog  clamp  is  removed  from  the 
vein,  its  place  being  taken  by  the 
thumb  and  first  finger  of  the  right 
hand  of  the  operator.  With  great 
care  the  clamp  controlling  the  ar- 
terial flow  is  now  gradually  released, 
coincidently  with  which  the  thumb 
and  finger  controlling  the  vein 
gradually  ease  up,  thus  permitting 
the  blood  to  go  over  gradually,  so 
as  to  prevent  any  possibility  of 
swamping  or  embarrassing  the  cir- 
culation of  the  recipient  by  a  sudden 
gush  of  blood  under  great  pressure. 
Let  it  be  strongly  emphasized  here 
that,  with  few  exceptions,  the  margin  of  safety  is  none  too 
great  in  any  transfusion  at  any  stage.  It  is  my  custom, 
therefore,  to  control  the  inflow  in  the  manner  above  described 
during  the  entire  course  of  the  transfusion. 

If  assistants  are  at  hand,  the  blood-pressure  and  pulse 
of  the  recipient  should  be  taken  at  intervals  of  every  three 
minutes,  that  of  the  donor  every  five  minutes.  These  meas- 
ures cause  but  slight  annoyance  to  the  patients  and  are  of 
the  utmost  importance  to  the  surgeon  in  judging  the  con- 
dition of  both  individuals.  Haemoglobin  and  red  counts,  made 
during  the  course  of  the  operation,  although  they  are  in- 
teresting and  valuable  do  not  give  nearly  so  helpful  imme- 
diate information  as  do  blood-pressure  and  pulse,  and,  since 
they  cause  more  or  less  discomfort  to  the  patients,  we  do 
not  make  these  readings  unless  there  is  some  special  reason 
for  them.  It  is  unnecessary  to  say,  of  course,  that  the  blood- 


FIG.  19. — Tube  tied  in  place  in  the 
artery. 


22  SURGERY  OF  THE  VASCULAR  SYSTEM 

pressure  and  pulse  of  both  donor  and   recipient  liavc  hccn 
taken  before  starting  the  transfusion,  as  a  control,  and  that 


Median 
Cephalic'V. 


FIG.  20. — Female  half  of  tube  tied  in  position  in  vein  of  the  recipient. 

if  the  facilities  are  at  hand,  a  complete  blood  examination- 
reds,  whites,  and  haemoglobin — has  been  made  of  both  pa- 


TRANSFUSION 


FIG.  21. — Tubes  invaginated  and  anastomosis  complete. 

tients,  also  as  a  control,  for,  after  completion  of  the  trans- 
fusion, these  data  are  most  valuable  in  interpreting  both  the 
immediate  and  future  results  of  the  operation. 


24  SURGERY  OF  THE  VASCULAR  SYSTEM 

Where  the  recipient  is  practically  exsanguinated,  and 
there  is  no  contraindication,  it  is  wise  to  give  him  all  the 
blood  he  can  conveniently  hold,  even  occasionally  (Crile) 
going  to  the  extent  of  using  two  donors  in  case  one  cannot 
stand  any  great  loss  of  blood.  My  routine  is  to  attempt  to 
bring  a  pulse  of  say  150  or  160  down  to  about  100  and  to  raise 
a  blood-pressure  of  50  to  70  up  to  110  or  120,  figures  well 
within  the  zone  of  safety. 

It  sometimes  happens  that  it  is  decidedly  unwise,  even 
hazardous,  to  overload  the  circulation,  an  example  of  such  a 
case  being  a  patient  exsanguinated  as  a  result  of  hemorrhage 
from  typhoid  (or  other)  ulcers  of  the  bowel.  To  give  such 
an  individual  much  blood  would  be  tempting  fate,  whereas  a 
small  amount,  sent  in  slowly,  will  decrease  the  coagulation 
time,  and  seal  up  the  mouths  of  open  vessels  with  life-saving 
thrombi.  In  other  words,  a  great  amount  of  blood  will 
simply  raise  the  blood-pressure  to  such  an  extent  that  it  will 
literally  blow  out  any  soft  young  plugs  that  might  be  all  that 
is  holding  body  and  soul  together. 

It  is  a  most  difficult  matter  to  judge  as  to  the  exact 
amount  of  blood  that  has  gone  or  is  going  over.  No  prac- 
tical method  of  measuring  the  amount  of  blood  flow  has  been 
devised,  and  until  this  much-desired  instrument  is  placed  at 
our  disposal  we  shall  be  compelled  to  depend  upon  clinical 
signs  for  an  index  of  the  amount  of  blood  transfused.  It 
must  be  recognized  that  a  number  of  factors  must  of  necessity 
enter  into  any  calculation  of  bulk.  The  blood-pressure,  be- 
cause of  the  psychic  disturbance  in  every  operation  of  this 
sort,  is  by  no  means  constant.  The  loss  of  blood  is  another, 
perhaps  the  chief,  factor  in  determining  the  instability  of 
the  blood-pressure  and  therefore  the  amount  that  goes  over 
in  bulk.  The  pulse-rate  varies,  too,  from  time  to  time  and 
this  must  be  considered  in  any  determination  of  amount. 
There  are  still  other  factors,  such  as  the  viscosity  of  the 
blood,  etc.,  which  need  not  be  considered  in  a  work  of  this 


TRANSFUSION  25 

character.  It  is  sufficient  to  say  that  to  the  careful,  ex- 
perienced surgeon  all  the  factors  above  mentioned  can  be 
determined  with  a  surprising  degree  of  accuracy  by  the  thumb 
and  forefinger  guarding  the  entrance  at  the  vein.  This  knowl- 
edge and  constant  observation  of  the  actual  blood-pressure 
reported  by  the  assistants,  the  general  appearance  of  the 
patients,  and  the  actual  time  that  the  blood  has  been  flowing 
• — all  this  serves  as  a  guide  to  the  amount  of  blood  going 
over  and  the  proper  time  to  cease  transfusing. 

In  regard  to  the  duration  of  actual  flow  in  transfusion 
in  general,  there  are  various  questions  to  be  considered.  An 
infant  will  require  but  a  small  amount  of  blood,  children 
need  far  less  than  adults,  and,  as  a  rule,  women  less  than 
men,  always  considering  that  the  patient  is  exsanguinated. 
A  big  husky  man  will  generally  have  a  larger  radial  than  a 
small  man,  and  his  pressure  will  enable  a  much  larger  and 
more  powerful  stream  to  be  thrown  by  his  vessel.  Likewise, 
a  female  donor  may  give  less  blood  in  a  given  time  than 
a  man — provided  the  man  is  not  too  badly  frightened.  Thus 
the  actual  time  of  transfusion  varies,  from  three  to  five 
minutes  to  one  hour  or  even  an  hour  and  a  quarter,  if  a  very 
small  cannula  is  used,  or  if  the  blood  has  been  permitted  to 
go  over  very  slowly.  For  most  transfusions  the  average 
duration  of  the  flow  is  from  twenty  to  forty  minutes.3 

The  welfare  of  the  donor  in  transfusion  must  be  carefully 
watched.  I  have  transfused  from  one  donor  for  over  an 
hour  without  any  signs  of  distress,  while  in  another  case 
fifteen  minutes  were  sufficient  to  produce  great  anxiety.  In 
general  a  sudden  fall  of  twenty  to  thirty  points  in  blood- 

3 1  have  proved  both  experimentally  and  clinically  that,  if  the  proper 
technic  has  been  observed,  blood  will  flow  through  my  two-pieced  cannula  from 
fifteen  to  thirty-five  minutes  without  clotting.  When  a  clot  does  occur,  it 
requires  but  a  few  moments  to  remove  the  tubes,  wash  out  both  vessels  with 
salt  solution  and  liquid  vaseline,  and  insert  another  set,  the  flow  being  again 
started  in  the  usual  manner.  Even  when  there  is  no  clot  I  have  occasionally 
found  it  of  advantage  to  arrest  the  transfusion  for  five  or  ten  minutes  in  order 
to  ease  and  reassure  the  patients. 


26  SURGERY  OF  THE  VASCULAR  SYSTEM 

pressure  should  warn  the  operator  that  the  limit  has  about 
been  reached.  Unfortunately,  however,  a  blood-pressure 
apparatus  is  not  always  at  hand  and  even  where  it  is  the 
fall  in  pressure,  sudden  or  gradual,  does  not  always  occur. 
In  such  instances  any  sudden  pallor,  accompanied  by  naus<>a 
and  vomiting,  continued  and  increasing  thirst,  great  restless- 
ness, together  with  a  decrease  in  blood-pressure  as  shown  by 
the  finger  of  the  operator  on  the  donor's  radial,  may  serve 
as  the  needed  danger  signal.  The  bleeding  should  never  be 
permitted  to  exceed  the  limit  of  safety;  the  donor  ought 
never  be  allowed  to  collapse  utterly.  A  proper  appreciation 
of  his  own  responsibility  as  well  as  the  moral  rights  of  those 
courageous  individuals,  generous  enough  to  give  of  their  own 
blood  that  another  might  live,  should  always  be  pre-eminent 
in  the  mind  of  the  surgeon  who  undertakes  work  of  this 
nature. 

The  danger  of  haemolysis  following  transfusion  has  always 
been  vastly  over-rated  and  unwarrantably  feared.  In  a 
rather  large  series  of  transfusions,  done  for  the  relief  of 
many  and  varied  conditions,  I  have  never  seen  it  occur,  and 
I  know  of  but  one  authentic  instance  where  it  complicated 
matters.  This  was  in  a  case  of  Dr.  John  L.  Yates  of  Mil- 
waukee (personal  note),  who  transfused  a  patient  exsanguin- 
ated as  a  result  of  hemorrhage  from  a  gastric  ulcer.  There 
was  a  rather  marked  but  temporary  haemolysis  following  the 
operation,  the  patient  making  a  good  recovery.  Crile  reports 
a  personal  case  in  his  book  on  "Hemorrhage  and  Trans- 
fusion" and  calls  attention  to  its  occurrence,  although  he, 
too,  regards  it  as  more  of  a  theoretical  than  a  practical 
menace. 

I  believe  that  the  proper  course  to  pursue — and  have  so 
practised — is  to  have  the  haemolytic  tests  of  donor's  and 
recipient's  blood  made,  if  the  case  is  not  urgent  and  when 
the  proper  facilities  and  trained  laboratory  workers  are  at 
hand.  If  the  case  is  urgent,  I  never  even  consider  such  a 


TRANSFUSION  27 

thing  as  haemolytie  tests,  contenting  myself  with  a  most  care- 
ful physical  examination  of  the  donor  in  order  to  rule  out 
the  possibility  of  transmitting  syphilis  or  some  other  disease 
to  the  recipient;  for  it  must  be  remembered  that  haemolytie 
tests,  even  at  best,  are  not  entirely  conclusive,  and  do  not 
absolutely  protect  against  haemolysis.  The  blood  of  one  in- 
dividual may  haemolize  that  of  another  in  the  test  tube,  but 
not  in  the  body  after  transfusion,  and,  vice  versa,  the 
laboratory  tests  may  pronounce  an  individual  a  suitable 
donor,  and  yet  haemolysis  may  occur  after  transfusion.  So 
that  until  some  absolutely  reliable,  uninvolved  test  has  been 
found,  the  rather  remote  danger  of  haemolysis  may  be  disre- 
garded in  emergency  cases,  in  the  home,  and  in  institutions 
where  the  facilities  for  making  these  tests  are  not  at  hand. 

REFERENCES 
Bernheim,  B.  M. :    A  Modification  of  the  C'rile  Transfusion  Cannula,  Annals  of 

Surgery,  Oct.,  1909. 
Bernheim,   B.   M. :     An   Emergency   Cannula;    Transfusion    in   a   Thirty-six-hour 

Old   Baby   Suffering  from   Melaena   Xeonatorum,   Jour.   Amer.   Med.    Assoc., 

April  6,  1912. 

Brewer,  G.  E.:    Jour.  Amer.  Med.  Assoc.,  Jan.  30,  1909,  p.  412. 
Cole.  H.  P.:    Transfusion  in  Pellagra,  Journ.  Amer.  Med.  Assoc.,  Feb.  25,  1911, 

No.  8. 

Crile.  G.  W. :    Hemorrhage  and  Transfusion,  Appleton  &  Co.,  1909. 
David,  V.  C.,  and  Curtis,  A.  H. :  Experiments  in  the  Treatment  of  Acute  Anaemia 

by  Blood  Transfusion  and  by  Intravenous  Saline  Infusion,  Surgery.  Gynae- 
cology, and  Obstetrics,  Oct.,  1912. 

Elsberg:  Jour.  Amer.  Med.  Assoc.,  1909,  vol.  Hi.  p.  887. 

Hahn,  Milton:    Haemophilia  Treated  by  Transfusion,  Med.  Record,  Oct.  8,  1910. 
Hepburn:    Annals  of  Surgery,  Jan.,  1909. 
Keator,    H.   M.:     Transfusion    in    Case   of   Toxaemia   of    Early    Pregnancy    with 

Unusual    Hemorrhagic    Manifestations.    Amer.    Jour.    Obstet.    and    Dis.    of 

Women  and  Children,  vol.  Ixv,  No.  414,  pp.  937-1131,  June,  1912. 
Morawitz:   Die  Behandlung  schwerer  Anamien  mit  Blut  Transfusionen.  Munch. 

med.  Woch..  April  16.  1907. 
Moss,  W.  L.,  and  Gelien.  J. :    Serum  Treatment  of  Hemorrhagic  Diseases,  Johns 

Hopkins  Hosp.  Bull.,  vol.  xxii.  No.  245.  July.  1911. 
Payr.  E.:    Zur  Technik  der  arterio-venosen  Bluttransfusion,  Munch,  med.  Woch., 

Bd.  59,  April  9.  1912. 
Pepper  and  Xesbit:     Fatal   Haemolysis   Following  Direct   Transfusion   of   Blood 

by  Arteriovenous  Anastomosis,  Jeur.  Amer.  Med.  Assoc.,  Aug.  3,  1907. 
Vincent,    Beth:      Blood    Transfusion.    Methods    and    Results,    Bost.    Med.    and 

Surg.  Jour.,  Aug.  22,  1912. 


CHAPTER  III 

END-TO-END  SUTURE 

Classical  End-to-end  Suture.  Exposure  of  Vessel;  IIV/.s//- 
ing  Process. — During  the  exposure  of  a  vessel  all  sources  of 
hemorrhage  should  be  scrupulously  controlled,  the  tissues 
should  be  handled  gently  and  sponged  with  gauze,  w<-t  with 
normal  salt  solution.  For  an  end-to-end  suture  of  an  artery 
two  Crile  clamps,  armed  with  soft  rubber  tubing,  should 
be  applied,  the  moment  the  vessel  is  sufficiently  exposed,  at 
a  distance  of  about  two  inches  apart,  all  branches  that 
come  off  between  them  being  clamped,  tied,  and  severed. 
The  vessel  is  then  divided  (Fig.  22)  and  the  blood  imme- 
diately washed  out  of  both  ends  with  normal  salt  solution, 
eye  droppers  or  pipettes  armed  with  rubber  bulbs  being  found 
most  suitable  for  this  purpose.  If  their  ends  have  been 
previously  carefully  rounded  by  flaming  they  can  be  intro- 
duced within  the  lumen  of  the  vessel  without  danger  of 
injuring  the  intima. 

Treatment  of  Adventitia. — This  washing  is  done  with  the 
utmost  care,  but  is  usually  interfered  with  by  a  soggy  layer 
of  whitish  tissue  hanging  over  the  end  of  the  vessel  and 
more  or  less  obstructing  the  lumen.  This  is  the  adventitia. 
which,  practically  devoid  of  elastic  tissue,  fails  to  contract 
on  severance  of  the  vessel  and  drops  lifeless  over  the  cut 
ends,  thus  obstructing  the  way.  It  should  be  picked  up  with 
the  first  finger  and  thumb,  or  preferably  with  a  delicate 
mouse-toothed  forceps,  pulled  well  out  over  the  ends  of  the 
vessel  (Fig.  23),  and  snipped  off  flush  with  the  cut  edge 
(Fig.  24).  Occasionally  all  of  it  will  be  gotten  the  first  tinio. 
but  if  any  loose  edges  are  left  they  should  again  be  treated 

28 


END-TO-END  SUTURE 


in  the  same  way,  following  which,  with  a  delicately  pointed 
forceps,  the  remaining  adventitia  should  be  stripped  back 

well  away  from  the  cut  edge.    Dur- 

.  ,  .          .  ,.   ,  ,. 

ing  this  time,  which  in  reality 
consumes  only  a  minute  or  two, 
the  washing  process  should  be 
continued  by  an  assistant.  When 


FIG.  22. — Severed    ends    of    an    artery 
showing  the  over-hang  of  adventitia. 


FIG.    23. — Drawing    adventitia    well    out 
over  end  of  the  artery. 


the  adventitia  is  completely  removed,  the  tip  of  the  pipette 
should  be  inserted  into  the  lumen  of  the  vessel  and  every 
visible  trace  of  blood  washed  out;  then  with  another  pipette 


30 


SURGERY  OF  THE  YASULAR  SYSTEM 


the  vessel  should  be  washed  and  soaked  outside  and  inside 
with  I'ujnid  raxrlim'  to  prevent  drying  and  keep  the  tissues 
soft  and  pliable  (Fig.  25).  The  process  of  washing  and 
soaking  with  salt  solution  and  liquid 
vaseline  should  be  continued  all  during 
the  process  of  the  operation,  and  an 
eye  should  constantly  be  kept  on  the 
adventitia,  which,  despite  the  utmost 
care,  will  often  literally  creep  down  to 
the  cut  edge  and  insinuate  itself  in  the 
line  of  suture. 

Hi  ay  Sutures;  Formation  of  Tri- 
angles.— Following  the  technic  so  beau- 
tifully developed  by  Carrel — and  later 
by  Stich — the  cut  ends  of  the  vessel  or 
vessels,  e.g.,  artery  or  vein,  to  be  united 
are  first  brought  together  by  three  stay 
sutures  placed  at  points  equidistant  around  the  lumen 
(Fig.  26).  These  sutures,  passed  in  such  a  way  that  the 
knots  will  be  on  the  outside  of  the  vessel,  are  tied  (Fig.  27), 
and  the  union  is  then  secured  by  sewing  in  succession 
each  side  of  the  triangle  thus  formed,  using  either  one  con- 
tinuous thread  with  a  tie  at  each  stay  suture,  or  using  the 
long  end  of  each  stay  to  sew  the  corresponding  side  of  the 
triangle.  During  the  process  of  the  suture,1  the  operator  holds 
in  his  left  hand  one  stay  suture  while  the  assistant  holds  in 
his  hand  the  corresponding  one,  thus  forming  a  straight  line 
of  the  edges  to  be  sewed  (Fig.  28).  A  light  clamp  should  be 
allowed  to  hang  on  the  third  stay  in  order  to  keep  the  other 
edges  from  being  caught  in  the  stitch. 

Over-and-over  Stitch. — As  one  side  is  finished  the  next 


FIG.  24. — Cutting  off  adventitia 
flush  with  end  of  the  artery. 


1  In  all  drawings  of  anastomosis  in  this  and  succeeding  chapters  the  femoral 
vessels  are  taken  as  a  type. 


END-TO-END  SUTURE 


31 


is  brought  into  position  by  rotation  of  the  stay  sutures  (Figs. 
29  and  30).     At  each  stroke  the  needle  passes  through  all 


FIG.  25. — Washing  out  vessels  with  liquid  vaseline  and  salt  solution. 

three  coats  of  both  vessels,  starting  on  the  outside  of  one, 
and  ending  on  the  outside  of  the  other,  thus  placing  all  knots 
outside  the  lumen.  The  stitch  is  a  simple  over-and-over  one, 


32  SURGERY  OF  THE  VASCULAR  SYSTEM 

each  needle  hole  being  placed  just  far  enough  back  from  the 
cut  edge  of  the  vessels  to  secure  comfortably  all  three  coats. 
No  set  rule  can  be  laid  down  as  to  the  number  of  stitcho  in 
any  one  side  of  the  triangle  or  in  the  whole  triangle;  Iliis 
must  of  necessity  depend  on  the  size  of  the  vessels,  but  the 


placed. 


sutures  must  neither  be  placed  too  close  together  nor  too 
far  apart.  The  approximation  of  the  cut  edges  of  the  vessels 
should  and  can  be  made  so  perfect  that  almost  no  irregularity 
is  apparent  to  the  naked  eye  (Fig.  31).  Despite  all  caution, 


END-TO-END  SUTURE 


33 


however,  it  frequently  happens  that  after  the  blood  flow 
is  started  there  are  one  or  two  little  leaks  that  must  be 
caught  up  with  an  interrupted  stitch.  This  is  best  done 


Fid.  27. — Stay  sutures  tied  and  vessel  triangulated. 

during  a  temporary  interruption  of  the  circulation,  and 
if  the  usual  care  be  observed  no  apprehension  need  be  felt 
by  operator. 

Toilet  of  Completed  Line  of  Suture. — Before  placing  any 


34 


SURGERY  OF  THE  VASCULAR  SYSTEM 


secondary  sutures,  however, — really  before  allowing  the  blood 
to  flow, — the  line  of  suture  should  be  carefully  wrapped  in 
dry  gauze  and  a  slight  compression  exerted  in  order  to  throw 


FIG.  28. — Sewing  first  side  of  triangle. 


Fio.  29.— Sewing  second  side  of  triangle ;  vessel  partially  rotated.    A  tie  is  placed  at  each  stay  suture. 

the  whole  strain  of  the  circulation  gradually  on  the  sutures. 
A  gentle  rolling  motion — massage-like — is  given  the  vessel 
at  the  same  time,  the  whole  process  being  continued  for  about 


END-TO-END  SUTURE 


35 


five  minutes,  during  which  time  the  little  needle  holes  and 

any  interspaces  that  are  not  too  large  will  fill  up  with  clot. 

If  this  seemingly  small  detail  is  conscientiously  carried  out 

and  a  gradual  relaxation  allowed  to  follow,  many  a  secondary 

stitch  that  under  other  circumstances 

would  be  needed  may  be  avoided.    It 

might  be  added  that  in  starting  the 

blood  flow  after  the  completion  of  a 

suture  the  distal  clamp  should  always 

be  released  first ;  otherwise  the  sudden 

rush  of  blood,  peremptorily  checked 

just  an  inch  or  so  beyond  the  line  of 

suture,  will  throw  a  terrific  strain  on 


FIG.  30. — Sewing  third  side  of 
triangle;  vessel  completely  rotated. 
Instead  of  complete  rotation,  re- 
verse rotation  may  be  practised  in 
order  to  bring  the  third  side  of  the 
triangle  into  view. 


FIG.  31. — Suture  complete. 


the  line  of  suture  that  is  both  unnecessary  and  dangerous. 
Any  one  who  can  perform  this  classical  end-to-end  anas- 
tomosis successfully  need  have  no  hesitation  about  attempting 
the  other  methods,  for  mechanically  they  are  all  easier  to 
carry  out,  and  the  general  technic  is  identically  the  same. 


36  SURGERY  OF  THE  VASCULAR  SYSTEM 

BEPEBENCES 

Bernheim,   B.   M.:     A  Note  on   Sonic    Methods   <>f    Anastomosing   Blood- Vessels, 

Johns  Hopkins  Hospital  Bull.,  April,  11)0!). 
Carrel,  A.:    The  Surgery  of  the  Blood-vessels,  etc.,  Johns  Hopkins  Hosp.    Mull., 

Jan.,  1907. 
Carrel,    A.:     Lea    anastomoses    vasculaires,    leur   technique    operatoire    ct    lours 

indications;  2e  Congres  des  mf-decins  le  langue  franchise  de  rAnu'rique  <lu 

Nord,  1904. 

Carrel,  A.:    La  technique  operatoire  des  anastomoses  vasculaires  et  de  la  trims- 
plantation  des  visceres,  Lyon  Me'dical,  1902. 
Carrel    and    Guthrie:    Uniterminal    and    Biterminal    Venous    Transplantations, 

Surgery,  Gynaecology,  and  Ohstetrics,  March,   1906. 
Carrel  and  Morel:    Anastomose  bout  a  bout  de  la  jugulaire  et  de   la  carotidc 

interne,  Lyon  Medical,  1902,  vol.  xcix,  p.  114. 
Dorrance:    An  Experimental  Study  of  Suture  of  Arteries,  with  a  Description  of 

a  Xew  Suture,  Annals  of  Surgery,  1906,  vol.  xliv,  p.  409. 
Hoepfner:     Ueber    Gefilssnaht    Gefsisstransplantationen    und    Replantation     von 

amputirten  Extremitiiten,  Inaugural  Dissertation,  Berlin,  1903. 
Payr,  R.:     Zur  Frage  der  circuliiren  Vereinigung  von  Blutgefiissen  mit  rcsorliir- 

baren  Prothesen,  Arch,  fiir  klin.  Chir.,  1904,  vol.  Ixxii,  p.  32. 
Stich,    Makkas,    Dowman:      Beitriige    zur    Gefiisschirurgie,    Beitriige    x.ur    klin. 

Chirurgie,  Bd.  53. 
Stich  and  Zoeppritz:     Zur  Histologie  der  Gefassnaht,  des  Gefass  u.  Organtran.-.- 

plantationen,  Beit,  zur  path.  Anat.,  xlvi,  1909,  p.  337. 
Watts:     The    Suture    of    Blood-vessels:    Implantation    and    Transplantation    of 

Vessels  and  Organs;  An  Historical  and  Experimental  Study,  Johns  Hopkins 

Hospital  Bulletin,  1907,  vol.  xviii,  p.  153. 


LATERAL,  anastomosis  of  blood-vessels  is  chiefly  employed 
in  uniting  an  artery  with  a  vein,  and  only  within  the  last  year 
or  so  has  serious  attention  been  directed  toward  developing 
this  suture  to  the  same  degree  of  perfection  that  has  been 
attained  with  the  end-to-end  method.  The  tardy  develop- 
ment of  this  operation  can  be  explained  by  the  fact  that  it 
has  only  become  a  working  necessity  since  our  recent  realiza- 


FIG.   32. — Diagram  showing  method  and  principle  of  making  incision  in  vessels  in  lateral  anasto- 
mosis according  to  the  method  of  Bernheim  and  Stone. 

tion  that,  in  cases  of  threatened  gangrene  of  the  extremities, 
where  arterial  flow  must  be  transferred  into  venous  channels, 
this  procedure  (lateral  anastomosis)  seems  not  only  theo- 
retically more  correct  but  gives  better  results  in  practice 
than  the  end-to-end  suture  (see  chapter  on  Reversal  of  the 
Circulation). 

Several  methods  of  uniting  vessels  side  to  side  have  been 
suggested — one  by  Carrel,  another  by  Hadda,  still  another 
by  Jeger — but  I  believe  that  none  answers  the  purpose  so 

37 


38  SURGERY  OF  THE  VASCULAR  SYSTEM 


Fio.  33. — Incision  made  in  side  of  artery  and  being  made  in  side  of  vein. 


LATERAL  ANASTOMOSIS 


39 


well,  theoretically  and  practically,  as  that  devised  by  me, 
Dr.  Harvey  B.  Stone  collaborating,  in  1910,  the  details  of 
which  are  as  follows : 

The  artery  and  vein  between  which  the  communication 
is  to  be  established  are  carefully  dissected  out,  and  bull-dog 
or  Crile  clamps,  rubber-shod,  are  applied  to  each  vessel  at 
corresponding  points.  The  incision  in  the  artery  is  made 
first.  A  sharp  cataract  knife,  held  transverse  to  the  long 


/        f 

FIG.  34. — Drawing  adventitia  away  from  the  oval  opening. 

axis  of  the  vessel  (Fig.  32),  is  plunged  through  the  artery  in  a 
direction  oblique  to  the  horizontal  plane  in  which  the  vessel 
lies,  so  as  to  form  a  sector  of  the  lumen  with  its  arc  equal 
to  about  one-third  of  the  circumference.  The  knife  is  thrust 
in  with  its  cutting  edge  upward  and  toward  the  adjacent  vein. 
The  overlying  one-third  of  the  artery  wall  is  then  divided. 
At  once  the  retraction  of  the  longitudinal  muscle  and  elastic 
fibres  causes  this  transverse  incision  to  gape  and  become  an 
open  ovoid.  Owing  to  the  fact  that  the  knife  was  entered 


40 


SURGERY  OF  THE  VASCULAR  SYSTEM 


obliquely  and  not  perpendicularly,  this  <>v<>i<l  (  Fig.  33)  looks 
toward  the  vein  and  also  somewhat  upward.  The  posterior 
edge  of  the  opening  is  thus  easily  accessible  for  suturing.  As 
soon  as  the  artery  is  opened  all  blood  is  washed  out  with  salt 
solution,  the  adventitia  stripped  off  carefully  (Figs.  .'14  and 
35),  and  the  lumen  and  other  surfaces  freely  bathed  with 
liquid  vaseline  (Fig.  36).  The  artery  is  then  protected  with 
vaseline-soaked  gauze,  and  a  similar  incision,  corresponding 

in  size  and  position,  is 
made  in  the  vein  so  that  it 
looks  toward  the  artery 
and  upward. 

The  suture  is  started 
by  passing  the  needle 
through  the  wall  of  the 
artery  from  without  in- 
ward, then  crossing  to  the 
vein  and  passing  here  from 
within  outward  (Fig.  37). 
When  this  suture  is  tied 
the  knot  lies  outside  the 
vascular  lumen.  From  this 
starting  point  a  simple 

Fio.  35.-Cutting  away  the  adventitia.  COntinUOUS   SUturG  (Fig.  38) 

is     carried     around     the 

openings  in  the  two  vessels,  care  being  taken  to  avoid  purse- 
stringing  !  (Fig.  39).  The  operation  is  completed  by  tying 
the  last  suture  to  the  remaining  long  end  of  the  first  tie 
(Fig.  40).  No  difficulty  is  experienced  in  approximating 
the  edges  of  the  incisions,  and  there  is  no  more  tension 
on  the  thread  than  in  an  end-to-end  anastomosis.  After 
completion  of  the  suture,  the  proximal  end  of  the  vein 
having  been  doubly  ligated  with  heavy  silk  about  one-half 

1  In    reality    the    thread    is    so    delicate    that    purse-stringing    is    almost   an 
impossibility. 


41 

to  three-fourths  of  an  inch  above  the  site  of  anastomosis, 
the  clamps  are  removed  first  from  the  vein,  as  in  all  vascular 
surgery.  If  any  marked  leakage  occurs,  the  weak  spots  are 
reinforced  by  one  or  two  extra  sutures.  Then  the  arterial 
flow  is  gradually  allowed  to  go  over  (Fig.  41).  During  the 
suturing,  intima  is  not  always  approximated  to  intima,  but 
with  the  establishment  of  the  arterial  stream  through  the 


FIG.  36. — Washing  out  the  vessel  with  salt  solution  and  liquid  vaseline. 

anastomosis,  the  "pull"  in  opposite  directions  between  the 
two  vessels  helps  to  bring  about  an  accurate  approximation. 
This  method  has  been  employed  with  great  satisfaction  a 
considerable  number  of  times  in  animals,  and  was  equally 
simple  in  execution  in  the  four  clinical  cases  in  which  I  have 
so  far  had  the  opportunity  to  try  it.  The  rationale  of  this 
method  has  been  deduced  from  a  consideration  of  the  cases 
of  arteriovenous  aneurism  met  with  in  the  clinic.  Previous 
laboratory  anastomoses  have  been  performed  by  making 
longitudinal  rather  than  transverse  incisions  in  the  vessels. 
In  the  clinical  cases  following  trauma  there  seems  little  doubt 


42  SURGERY  OF  THE  VASCULAR  SYSTEM 

that  the  wounds  are  transverse.     A  bullet,  knife-blade,  or 
other  object  wounds  the  adjacent  surfaces  of  artery  and  vein 


/-* 


;'  ^mf^F 

FIG.  37. — Starting  suture  of  the  vessels.     The  knot  is  placed  outside  the  lumen. 


FIG.  38. — Posterior  row  of  sutures  being  placed. 


at  the  same  level.    The  vessels  are  held  closely  together  by 
their   investing   sheaths,   the  transverse   incisions   gape,   as 


43 


illustrated  in  these  sketches,  and  the  gaping  lips  soon  adhere. 
The  method  described  in  this  paper  is  practically  a  copy  of 
this  accidental  anastomosis  occurring  in  nature. 


FIG.  39. — Posterior  row  of  sutures  completed;  anterior  row  being  placed.      One  continuous  suture. 


FIG.  40. — Suture  completed  and  being  tied  to  first  knot — outside  the  lumen  of  both  vessels. 


44  SURGERY  OF  THE  VASCULAR  SYSTEM 


Fio.  41. — Clamps  removed  from  vessels.     Proximal  ligation  of  vein.      Blood  is  goim?  down   both 

artery  and  vein. 


LATERAL  ANASTOMOSIS  45 

I  think  that  this  anastomosis,  with  a  ligation  of  the  vein 
on  the  cardiac  side  of  the  point  of  union,  offers  a  much 
easier  and  safer  method  for  reversal  of  the  circulation  than 
the  present  procedure  of  end-to-end  anastomosis  of  artery 
and  vein,  with  ligation  of  the  proximal  stump  of  the  vein  and 
the  distal  stump  of  the  artery.  When  the  latter  method  is 
used  a  failure  of  the  anastomosis  imperils  the  knee  or  elbow, 
owing  to  the  complete  division  of  the  arterial  trunk;  and 
as  a  rule  the  disease  process  which  leads  one  to  do  an 
arteriovenous  anastomosis  is  not  in  itself  so  advanced  as  to 
threaten  the  larger  joints.  In  the  few  experiments  with  the 
new  method  in  which  thrombi  developed,  they  never  obliter- 
ated the  arterial  lumen  but  were  entirely  lateral.  Moreover, 
by  this  procedure  the  inflow  of  blood  into  a  threatened  ex- 
tremity still  has  whatever  arterial  channels  remain  patent, 
and  the  venous  trunk  in  addition  may  be  utilized  to  carry 
some  of  the  needed  excess.  It  is  important  to  ligate  the  vein 
above  the  anastomosis,  to  protect  the  heart  from  a  direct 
back  flow  of  blood  under  arterial  pressure  into  its  right 
chamber. 

In  brief  conclusion,  this  method  is  presented  because  of 
its  easy  execution,  making  it  superior  to  the  longitudinal  in- 
cision for  experimental  work,  and  because  of  its  safety, 
making  it  better  than  the  end-to-end  for  reversal  of  the 
circulation  and  other  clinical  conditions. 

REFERENCES 
Bernheim.  B.  M.,  and  Stone,  H.  B.:     Lateral  Vascular  Anastomosis,  Annals  of 

Surgery,  Oct.,  1911,  p.  496. 
Carrel.    A.:     Les    anastomoses    vasculaires.    leur    technique    operatoire    et    leurs 

indications:    2e  Congr§s  des  medecins  le  langue  franc.ais  de  1'Amerique  du 

Nord,  1904. 
Carrel,  A.:     The  Surgery  of  the  Blood-vessels,  etc.,  Johns  Hopkins  Hosp.   Bull., 

Jan.,  1907. 
Hadda.   S. :     Anlegung  arterio- venose  Anastomosen  bei  erhaltenem  Blutkreislauf, 

v.  Langenbeck's  Archiv,  Bd.  94,  Hft.  3,  1911. 
Jeger,  Ernst:      Eine  neue  Klemme  zur  Herstellung  von  Seit-zu-seitanastomosen 

zwischen    Blutgefassen    ohne    Unterbrechung    des    Blutstromes,    Zentralb.    f. 

Chir.,  Xo.  18,  p.  004,  1912. 


CHAPTER  V 


TRANSPLANTATION  OF  A  SEGMENT  OF  VEIN  OR  ARTERY 

IT  sometimes  occurs  that  the  continuity  of  a  vessel — in- 
terrupted by  accident  or  operation — cannot  be  restored  by 
simple  end-to-end  suture  because  of  the  length  of  the  defect. 
In  such  instances,  where  it  is  either  unwise  or  undesirable 
simply  to  ligate  the  ends  of  the  vessels  and  drop  them  back, 

it  becomes  necessary  to  bridge 
the  defect  by  transplanting  a 


Fio.  42. — Washing  out  a  venous  trans- 
plant with  liquid  vaseline  and  salt  solu- 
tion. 


FIG.  43. — Cutting  adventitia  away  from 
edges  of  venous  transplant. 


piece  of  artery  or  vein.  The  segment  to  be  transplanted  is 
best  taken  from  another  part  of  the  body  of  the  patient, 
although  one  removed  from  another  individual  will  answer. 
Indeed,  the  recent  work  of  Carrel  tends  to  show  that  vessels, 
removed  and  properly  prepared,  can  be  kept  in  cold  storage 
without  deterioration  for  months  before  being  subjected  to 
46 


TRANSPLANTATION  OF  SEGMENT  OF  VEIN      47 

transplantation.  It  goes  without  saying  that  the  transplant 
must  be  from  the  same  species  as  the  patient.  The  cold 
storage  tissue  is  not  at  present  practically  available. 


FIG.  44. — Measuring  venous  transplant  between  ends  of  artery. 


48 


SURGERY  OF  THE  VASCULAR  SYSTEM 


While  transplants,  as  stated  above,  may  be  either  arterial 
or  venous,  they  are  in  reality  nearly  always  venous,  because 
arteries  cannot  be  spared  from  the  body  as  can  veins.  For 
example,  it  would  be  unwise  to  say  the  least  to  remove  a 
segment  of  the  femoral  or  brachial  artery  of  a  patient— 
or  one  of  his  friends — to  supply  a  defect  in  his  popliteal 


Fio.    45. — The    transplant    "set"    by 
stay  sutures  placed  at  either  end. 


FIG.  46. — Suture  in  progress. 


artery  created  by  removal  of  an  aneurism.  However,  he 
could  well  spare  a  piece  of  his  internal  saphenous  vein,  and 
as  experiments  have  shown  that  a  segment  of  vein  interposed 
between  two  ends  of  an  artery  rapidly  becomes  able  to  with- 
stand the  arterial  pressure  by  a  hypertrophy  of  its  walls,  it 
is  customary  for  purposes  of  transplantation  to  utilize  a  seg- 


TRANSPLANTATION  OF  SEGMENT  OF  VEIN      49 


ment  of  the  internal  saphenous  vein  (Figs.  42  and  43)  or 
some  other  easily  accessible. 

The  operation  is  always  accomplished  by  means  of  an 
end-to-end  suture  according  to  the  method  described  in  Chap- 
ter III.  One  or  two  additional  suggestions,  however,  may 
be  in  order.  In  the  first  place  a  careful  inspection  of  the 
lumen  of  the  vein  should  always  be 
made  to  ascertain  the  presence  or 
absence  of  valves.  This  can  nearly 
always  be  definitely  determined  by 
inspection  of  the  intact  vein  before 
removing  the  segment,  and  it  can  also 
be  determined  after  removal  by  in- 
jecting salt  solution  or  liquid  vaseline 
through  the  lumen.  If  valves  are 
present  the  fluid  will  pass  easily 
through  the  vessel  in  one  direction,  but 
going  the  opposite  way  it  will  be  ob- 
structed and  the  vein  will  bulge  at  the 
site  of  the  valves.  By  taking  this 
precaution  one  can  " reverse"  the  vein 
segment,  or  in  other  words  interpose 
it  between  the  cut  ends  of  the  artery 
with  the  valves  facing  distally. 

Secondly,  the  segment  must  be"  the 
proper  length.     This  is  not  so  easily     FIG.  47.— suture  complete;  vein 

Tin  •,         'TJ_  i  flaccid;  clamps  still  on  the  artery. 

accomplished  as  it  might  seem,  because 

the  segment  contracts  (decreases  in  length)  the  moment  it 
is  removed,  and  expands  (increases  in  length)  almost  to 
the  normal  as  soon  as  it  is  transplanted  and  the  blood  flow 
started.  Obviously,  then,  unless  great  care  is  exercised,  the 
transplant  will  be  so  short  that  the  delicate  thread  used  in 
suturing  will  be  unable  to  stand  the  tension  necessary  to 
"set"  the  ends,  or  it  will  be  so  long  that  when  the  blood  goes 


50 


SIRGERY  OF  THE  YASCTLAR  SYSTEM 


through,  the  segment  will  form  a  half  curve,  even  an  S,  iu 
the  line  of  the  parent  artery.    Generally  speaking,  the  usual 


FIG.  48. — Blood  going  through  the   transplant.     Vein   bulged   and  tense  from  arterial  pressure. 
Slight  irregularity  indicates  situation  of  reversed  valves. 

procedure  is  to  start  out  with  a  segment  that  is  definitely 
too  long  and  to  trim  it  down  with  a  pair  of  very  sharp 


TRANSPLANTATION  OF  SEGMENT  OF  VEIN      51 


scissors  or  preferably  a  sharp  knife.  A  good  working  rule 
is  to  have  the  segment  finally  about  one-quarter  of  an  inch 
or  even  one-half  inch  shorter  (Fig.  44)  than  the  actual  defect 
it  is  to  fill. 

Thirdly,  it  is  always  wise  to  attach  both  ends  of  the 
transplant  to  the  parent  vessel  by  means  of  the  usual  three 
stay  sutures  (Fig.  45),  before  beginning  the  actual  suture  of 
either  end  (Fig.  46).  There  will  thus  be  less  handling  and 
consequently  less  danger  of  injury  to  the  vessel. 

As  soon  as  both  lines  of  suture  are  completed  (Fig.  47), 
the  segment  transplanted  is  carefully  wrapped  in  dry  gauze 
and  the  blood  flow  gradually  started 

by  removing  the  distal  clamp  en-  ±.  ^^Bfc. 

tirely,  the  proximal  only  partially. 
As  the  vessel  is  felt  to  bulge  under 
the  gauze,  the  fingers  start  a  gentle 
massage-like  motion  over  the  suture 
lines,  exerting  a  little  pressure  at 
the  same  time.  If  there  is  no  alarm- 
ing hemorrhage,  the  proximal 
clamp,  previously  loosened,  is  now 
entirely  removed,  and  the  massage- 
like  motion  and  pressure  are  con- 
tinued for  about  five  minutes,  after  which  there  is  a  gradual 
cessation  of  the  pressure  and  a  careful  removal  of  the  en- 
circling gauze  (Figs.  48  and  49). 

If  the  sutures  have  been  carefully  made  and  the  above- 
mentioned  details  have  been  observed,  there  will  be  little 
need  for  any  secondary  stitches.  They  are,  however,  occa- 
sionally required  in  spite  of  all  efforts,  and  are  best  placed 
as  interrupted  stitches  during  a  temporary  stoppage  of  the 
circulation,  the  gauze  and  pressure  being  reapplied  as  the 
flow  is  started. 


FIG.  49. — Valves  of  vein — diagram 
showing  necessity  for  reversal  in  placing 
a  venous  transplant. 


52  SURGERY  OF  THE  VASCULAR  SYSTEM 

When  all  bleeding  has  once  been  successfully  controlled, 
it  is  most  unlikely  to  recur  if  the  proper  care  is  exerted  in 
closing  the  wound. 

REFERENCES 

Bernheim,  B.  M. :  Arteriovenous  Anastomosis — Reversal  of  the  Circulation — a* 
a  Preventive  of  Gangrene  of  the  Extremities,  Annals  of  Surgery,  Feb.,  IS)  1:2. 

Borst  and  Enderlen:  Ueber  Transplantation  von  Gefiissen  und  ganzen  Organen, 
Deut.  Zeit.  f.  Chir.,  Bd.  99,  Heft  1-2. 

Carrel,  A.:  Anastomosis  and  Transplantation  of  Blood-vessels,  American  Medi- 
cine, August,  1905. 

Carrel,  A.:  Latent  Life  of  Arteries,  Jour,  of  Exper.  Mfd.,  I'.HO.  vol.  xii. 
pp.  460-486. 

Faykiss,  Franz  v. :  Ueber  Gefiisstransplantationen,  Beitr.  /.ur  klin.  C'liir.,  Bd.  78, 
Heft  3. 

Goecke:  Extirpation  eines  Aneurysina  der  Art.  poplitea  und  ersatz  des  Defekts 
durch  freie  Transplantation  eines  Sttickes  der  Vena  saphena,  Med.  Klinik. 
1912,  p.  105,  No.  3. 

Omi,  K. :  Beitriige  zur  idealen  Aneurysma-operation.  Ueber  die  zirkulr.sc 
Gefiissnaht  und  fiber  die  Transplantation  der  Gefasse  am  Menschen,  Dent. 
Zeit.  f.  Chir.,  1912,  Bd.  118,  Heft  1-2. 

Watts,  Stephen  H. :  The  Suture  of  Blood-vessels;  Implantation  and  Transplan- 
tation of  Vessels  and  Organs;  An  Historical  and  Experimental  Study.  Johns 
Hopkins  Hosp.  Bull.,  1907,  vol.  xviii,  p.  153. 

Yamanouchi:  Ein  Beitrag  zur  idealen  Operation  des  arteriellen  Aneurysma. 
Deut.  Zeit.  f.  Chir.,  1912,  Bd.  118,  Heft  1-2. 


CHAPTER  VI 

ARTERIOVENOUS  ANASTOMOSIS — REVERSAL  OF  THE  CIRCULATION 

ARTERIOVENOUS  anastomosis  or  so-called  reversal  of  the 
circulation  l  is  an  operation  charily  employed  at  present,  but 
capable  of  great  development  for  the  relief  of  many  condi- 
tions. To  illustrate  the  use  of  the  procedure,  in  the  supposed 
case  of  an  obstruction  in  an  artery  caused  by  a  thrombus  or 
growth,  where  it  is  inconvenient  or  impossible  to  make  a 
complete  arterial  or  venous  transplant,  after  resection  of  the 
artery  its  proximal  end  can  be  united  to  the  distal  end  of  a 
severed  vein.  After  extirpation  of  an  aneurism  or  a  growth 
involving  the  vessels,  an  arteriovenous  anastomosis  may  be 
the  most  desirable  operation  to  overcome  the  break  in  the 
circulation.  In  cases  of  threatened  gangrene  of  the  extrem- 
ities resulting  from  obstruction  of  the  arterial  channel,  this 
operation  may  be  the  only  means  of  saving  the  limb. 

The  operation  may  be  accomplished  either  by  means  of  the 
end-to-end  method  of  Carrel,  or  by  a  lateral  suture.  Since 
the-  union  of  the  vessels  for  the  relief  of  this  condition  is 
always  made  in  Scarpa's  triangle  in  the  leg,  and  in  or  just 
below  the  axilla  in  the  arm,  the  end-to-end  method  requires 
the  vessels  to  be  severed  in  regions  which  are  usually  far 
above  the  site  of  the  obstruction.  In  the  method  of  lateral 
anastomosis  the  artery,  being  undisturbed,  is  left  to  carry 
the  blood  as  far  as  the  obstruction,  the  burden  of  carrying  it 
further  being  shifted  to  the  vein.  In  other  words  the  end- 
to-end  method  unnecessarily  destroys  entirely  a  channel 
that  is  only  partially  blocked,  while  the  lateral  method 
leaves  it  intact,  simply  adding  another  channel  by  means  of 
which  the  blood  may  be  carried  as  far  as  necessary.  For 

1  First  performed  by  San  Martin  y  Satrustegui  in  1902. 

53 


54  SURGERY  OF  THE  VASCULAR  SYSTEM 

this  reason  those  who  have  had  most  experience  with  this 
operation  now  exclusively  employ  the  lateral  method,  unlos. 
as  happened  in  one  of  my  cases,  the  artery  is  blocked  almost 
throughout  its  entire  course. 

During  recent  years  a  number  of  attempts  to  reverse  the 
circulation  of  a  limb  have  been  made,  most  of  them  ending 
in  failure.  In  February,  1912,  I  collected  and  reported  52 
cases  myself,  only  15,  or  30  per  cent,  of  the  total  number, 
being  considered  successful.  The  seemingly  poor  result >  in 
this  field  of  work  had  previously  given  rise  to  a  certain  amount 
of  scepticism  as  to  the  possibility  of  performance  of  this 
operation  from  a  physiological  standpoint,  and  had  caused  a 
discussion  between- Coenen  of  Breslau  and  Wieting2  of  Con- 
stantinople as  to  the  efficacy  of  an  arteriovenous  anastonm-i- 
— reversal  of  the  circulation — in  preventing  the  spread  of  a 
real  or  threatened  gangrene  in  the  extremity  of  a  human. 

Coenen  claims  that  Carrel's  statements  and  experiments 
in  regard  to  the  possibility  of  reversing  the  circulation  in  a 
dog  are  not  conclusive;  that,  in  fact,  the  valves  of  the  veins 
do  not  give  way  as  Carrel  asserts,  and  that  as  a  result  a  true 
and  complete  reversal  is  never  attained,  the  blood  being 
simply  shunted  off  to  another  vein  and  promptly  returned  to 
the  heart  without  ever  getting  to  the  foot  or  hand.  He  further 
asserts  that  the  procedure  is  both  anatomically  and  physio- 
logically wrong,  and  he  therefore  warns  against  the  indis- 
criminate use  of  the  operation. 

Wieting,  on  the  other  hand,  claims  that  in  his  hands  the 
operation  is  clinically  quite  successful,  although  he  admits 
that  several  questions,  such  as  the  return  of  the  blood  to 
the  heart,  are  still  unsettled.  He  is  of  the  opinion  that  tin-so 

*This  operation  is  known  abroad  as  Wietinp's  operation.  If  it  is  to  go  by 
any  man's  name  it  should  be  that  of  San  Martin  y  Satrustegui,  who,  as  noted 
above,  first  performed  the  operation  clinically.  I  prefer  to  call  it  reversal  of 
the  circulation. 


ARTERIOVENOUS  ANASTOMOSIS  55 

doubtful  points  can  be  solved  only  through  clinical  experi- 
ence, theories  and  experimental  work  not  having  given  the 
required  solution. 

After  his  first  utterance  on  the  subject  Coenen  continued 
his  experimental  work  and  claims  in  later  publications  to 
have  obtained  additional  evidence  in  support  of  his  views, 
while  Wieting  continues  to  have  a  varying  amount  of  success 
clinically  with  the  operation. 

I  feel  that  there  can  be  little  doubt  as  to  the  correctness 
and  truth  of  Carrel's  assertion  that  complete  reversal  of  the 
circulation  is  possible  in  the  dog.  Experienced,  careful 
worker  that  he  is,  unexcelled  as  a  technician,  his  articles  must 
convince  any  unbiased  reader,  and  his  beautiful  specimens, 
showing  destruction  of  the  vein  valves  by  the  arterial  current, 
speak  for  themselves.  Even  Gruthrie  ("Blood  Vessel  Sur- 
gery," p.  161)  admits  the  possibility  of  reversal  in  the  limb 
of  a  dog,  while  denying  this  for  the  human,  although  his  ex- 
perience with  the  latter  was  nil,  and  his  deductions  entirely 
theoretical.  My  own  animal  experiments  are  in  accordance 
with  those  of  Carrel  and  Guthrie,  and  it  is  inexplicable  to  me 
why  Coenen  was  unable  to  get  similar  experimental  results. 

Practically,  in  dealing  with  the  human,  the  matter  is  some- 
what different.  Pathological  considerations,  such  as  arterio- 
sclerosis, thrombo-angeitis  obliterans,  etc.,  give  rise  to  com- 
plications not  encountered  in  experimental  work.  The  opera- 
tion must  not  be  attempted  in  the  presence  of  these  conditions, 
not  only  because  the  blood  cannot  be  driven  through  a  channel 
that  is  obstructed  or  obliterated,  but  also  because  vessels 
diseased,  hardened,  thickened,  and  roughened  inside  do  not 
permit  of  a  successful  suture — a  thrombus  will  invariably 
form  at  the  line  of  suture  because  the  endothelial  lining  of 
the  vessel  is  abnormal  or  even  at  times  lacking. 

It  is  likewise  a  mistake  to  attempt  to  save  a  limb  already 
lost,  one  that  is  so  far  advanced  in  the  process  of  gangrene 


56  SURGERY  OF  THE  VASCULAR  SYSTEM 

as  to  put  beyond  question  any  hope  of  its  rescue.  These  and 
other  factors  related  to  the  subject  I  have  tried  to  emphasize 
in  articles  written  during  the  last  four  years.  It  is  impossible 
to  bring  the  dead  back  to  life ;  it  is  a  hopeless  task  to  attempt 
the  rejuvenation  of  sclerosed  or  thrombosed  blood-vessels; 
yet  this  has  all  but  been  attempted,  not  once  but  many  times. 
One  has  but  to  read  the  reports  of  the  various  cases  to 
realize  the  absolute  hopelessness  of  many  of  those  chosen. 
It  is  little  wonder  that  doubt  arose  as  to  the  possibility  of 
accomplishing  this  operation,  which,  by  exercising  proper 
care  in  selecting  the  case,  and  in  the  hands  of  an  operator 
skilled  in  the  suturing  of  blood-vessels,  is  an  entirely  feasible 
procedure. 

Cases  must  be  secured  before  actual  gangrene  arises— 
that  is,  in  the  stage  of  threatened  gangrene.  If  gangrene  has 
already  set  in,  it  is  best  to  let  the  process  subside  or  localize, 
and  then  to  do  the  reversal  in  the  hope  of  preventing  further 
encroachments.  The  age  of  the  patient  has  little  or  nothing 
to  do  with  the  question;  the  condition  of  his  limb  and  the 
age  and  condition  of  his  vessels  are  paramount  in  importance. 

It  must  be  remembered  that  senile  gangrene  is  not  the 
only  form  of  gangrene.  Certain  cases  of  Raynaud's  disease 
frequently  progress  to  the  stage  of  threatened  or  real  gan- 
grene, and  occasionally  an  embolus  lodging  in  an  artery  will 
give  rise  to  most  alarming  circulatory  disturbances,  some- 
times causing  actual  gangrene.3  All  such  cases,  properly 
selected,  should  be  subjected  to  reversal  of  the  circulation 
rather  than  amputation,  an  operation  that  is  being  gradually 
discarded  by  the  modern  surgeon. 

I  have  reversed  the  circulation  in  the  hope  of  preventing 
gangrene  nine  times,  with  six  successes,  one  doubtful  case, 

*No  case  of  diabetic  gangrene  has  as  yet  presented  itself  for  operation. 
I  Bee  no  reason  why  the  operation  should  not  be  done  in  this  condition  in 
suitable  cases. 


ARTERIOVENOUS  ANASTOMOSIS  57 

and  two  failures,  amputation  being  required  in  the  last  two. 
There  was  no  mortality,  and  in  my  opinion  there  is  no  reason 
for  a  greater  mortality  following  this  operation  than  after 
any  other  of  equal  severity.  I  hold  this  view  notwithstanding 
the  discouraging  records  of  similar  cases  in  the  hands  of 
other  surgeons,  who,  I  think,  have  met  such  ill  success  prin- 
cipally because  their  patients  were  so  weakened  at  the  time 
of  operation  that  they  could  not  withstand  its  shock, — just 
as  they  would  have  been  unfit  to  withstand  the  shock  of  any 
other  operative  measure.  Unfortunately,  convalescence  in  a 
number  of  the  recorded  cases  has  been  cut  short  by  infection. 
In  answer  to  the  contention  of  Coenen  and  his  followers 
that  the  blood  is  unable  to  force  the  vein  valves  and  that 
therefore  it  does  not  flow  down  the  vein  to  any  great  extent, 
I  wish  to  cite  the  case  of  one  of  my  patients,  a  young  woman 
now  twenty-eight  years  of  age,  in  whom  I  have  successfully 
reversed  the  circulation  of  all  four  extremities  to  prevent 
both  real  and  threatened  gangrene  and  to  relieve  excruciating 
pain  in  a  severe  case  of  Raynaud's  disease.  In  February, 
1911,  I  performed  an  end-to-end  anastomosis  of  the  femoral 
artery  and  vein  (in  Scarpa's  triangle)  of  the  left  leg,  and  in 
May  of  the  same  year  a  lateral  anastomosis,  according  to  the 
method  of  Bernheim  and  Stone,4  of  the  femoral  vessels  of  the 
right  leg.  Complete  relief  was  obtained  in  the  left  limb,  but 
the  intervention  of  another  surgeon  ten  days  previous  to  my 
operation  lessened  the  degree  of  success  in  the  right.  In  the 
hope  of  avoiding  the  vascular  operation  in  this  leg,  the 
sciatic  nerve  of  the  patient  had  been  stretched — after  which 
the  pain  not  only  was  augmented  but  paraesthesia  of  the  lower 
limb  and  a  foot-drop  occurred — conditions  which  the  reversal 
which  followed  could  not  be  expected  to  relieve.  The  circu- 
lation in  this  limb,  however,  was  restored,  and  its  general  con- 

4  See  chapter  on  Lateral  Anastomosis. 


58  SURGERY  OF  THE  VASCULAR  SYSTEM 

dition  has  improved — but  the  pain  has  persisted,  though 
lessened. 

Early  in  1912,  the  same  condition — pain,  actual  and  threat- 
ened gangrene — necessitated  reversal  of  the  circulation  in 
both  arms  of  this  patient.  This  was  successfully  performed 
on  January  23,  1912,  in  the  left  arm,  and  on  March  5  of  the 
same  year  in  the  right  arm, — lateral  anastomosis  of  the 
brachial  artery  and  vein  at  the  lower  edge  of  the  axilla  being 
the  operative  procedure  in  each  instance. 

At  the  time  of  operation  on  the  left  arm,  the  little  finger 
of  that  hand  was  partially  gangrenous  and  amputation  was 
postponed  only  in  the  hope  that  reversal  might  save  it.  I  am 
happy  to  report  that  the  circulation  improved  in  that  finger 
immediately  after  the  operation  and  remained  so  good  that  ;i 
slough  formed  and  the  finger  healed  perfectly  within  a  short 
time  thereafter. 

The  patient  has  been  relieved  of  all  symptoms  in  all  ex- 
tremities except  the  right  leg,  where  the  lack  of  complete 
success  has  been  explained.  She  is  now  active  and  able  to 
attend  to  her  duties.  A  definite  pulsation  can  be  felt  at  the 
sites  of  all  four  anastomoses  and  can  be  followed  down  the 
veins  of  both  arms  well  below  the  elbows.  Indeed,  pulsation 
can  even  be  seen  in  the  veins  of  the  arms.  In  the  legs  pul- 
sation can  only  be  felt  a  few  inches  below  each  fistula,  but 
this  is  due  to  the  great  thickness  of  the  tissues  overlying  the 
vessels  in  the  lower  extremities.  In  addition  to  the  palpable 
pulsation,  there  is  a  definite  thrill  at  the  site  of  each  anasto- 
mosis which  is  easily  felt.  It  can  be  followed  down  the  lower 
extremities  with  the  fingers  only  an  inch  or  so,  because  of  the 
thickness  of  the  overlying  tissues,  but  in  the  arms  it  is  beau- 
tifully traced  to  and  below  the  elbow.  With  the  stethoscope 
these  thrills  are  heard  to  be  quite  powerful, — humming-top 
in  character.  In  the  lower  extremities  they  can  be  traced 
down  into  the  popliteal  spaces,  in  the  arms  to  both  wrists. 

The  patient  was  shown  before  The  Interurban  Orthopedic 


ARTERIOVENOUS  ANASTOMOSIS  59 

Club  which  met  at  the  Johns  Hopkins  Hospital,  November  18 
and  19,  1912.  At  that  time,  in  addition  to  being  examined  by 
the  members  of  the  club,  she  was  examined  by  Dr.  W.  S. 
Halsted  and  Dr.  John  M.  T.  Finney,  all  of  whom  agreed  that 
the  blood  was  definitely  going  down  the  veins.  The  case  has 
also  been  passed  upon  by  Dr.  Joseph  C.  Bloodgood,  in  whose 
clinic  at  St.  Agnes'  Hospital  and  by  whose  courtesy  I  was 
privileged  to  do  the  operations. 

I  have  given  a  detailed  account  of  this  case  because  it  is 
the  only  existing  record  of  successful  reversal  of  the  circu- 
lation in  all  four  extremities  of  the  same  individual,  and  I 
offer  it  as  incontrovertible  substantiation  for  upholding  this 
operation. 

I  summarize  herewith  the  necessary  precautions  to  be  ob- 
served before  proceeding  to  operation  in  a  case  of  this  sort : 

1.  Select  the  cases  with  utmost  care,  (a)  ruling  out  those 
in  which  a  fulminating  gangrene  is  present;  (b)  ruling  out, 
or  postponing  until  the  condition  is  improved,  those  in  which 
the  patient  is  so  debilitated  as  to  be  unable  to  withstand  any 
operative  procedure;  (c)  ruling  out  those  in  which  the  vessels 
(artery   and   vein)    are   evidently   obstructed   or   markedly 
sclerosed. 

2.  If  there  is  any  doubt  about  any  case,  cut  down  upon 
and  expose  the  vessels;  then,  if  they  are  suitable  for  anas- 
tomosis, the  operation  can  proceed ;  if  not,  it  is  best  to  resort 
immediately  to  amputation. 

3.  Last  and  most  important,  the  operator  must  be  a  man 
of  experience  and  good  judgment  in  vascular  surgery. 

I  conclude  this  chapter  with  emphasis  of  the  fact  that 
relief  from  pain  cannot  always  be  relied  upon  to  follow  im- 
mediately after  operation.  Sometimes  it  does,  but  in  other 
cases  it  is  withheld  for  days,  sometimes  weeks.  Anodynes 
should  be  freely  given.  The  limb  should  be  kept  in  a  plaster 
cast  for  three  weeks.  At  the  end  of  the  first  week  it  should 


60  SURGERY  OF  THE  VASCULAR  SYSTEM 

be  removed  for  the  taking  out  of  skin  stitches  and  for  an 
examination  by  stethoscope  of  the  anastomosis.  If  at  this 
time  a  thrill  can  be  heard  and  the  gangrene  is  checked  or 
averted,  the  operator  is  justified  in  anticipating  success.  The 
absence  of  the  thrill,  however,  at  this  time  need  not  be  in- 
terpreted as  an  indication  of  failure,  unless  the  gangrenous 
condition  has  become  aggravated. 

REFERENCES 

Bernheim,  B.  M.,  and  Stone,  H.  B. :    Lateral  Vascular  Anastomosis,  Annals  of 

Surgery,  Oct.,  1911,  p.  4!»(i. 
Bernheim,  B.  M. :    Arteriovenous  Anastomosis — Reversal  of  the  Circulation — as 

a  Preventive  of  Gangrene  of  the  Extremities,  Annals  of  Surgery,  Feb.,  l!M2, 

p.  195. 
Bernheim,    B.    M. :      Arteriovenous    Anastomosis — Successful     Reversal    of    the 

Circulation   in  all   Four  Extremities  of  the  Same  Individual,  Jour.  AHUM. 

Med.  ABSOC.,  Feb.,  1913,  p.  360. 
Buerger,   L. :     Thrombo-angeitis   Obliterans;    a    Study   of   the   Vascular   Lesions 

Leading   to   Presenile   Gangrene,   Amer.   Jour.   Med.   Sc.,    1908,   vol.   cxxxvi, 

p.  567. 
Buerger,    L. :      The    Veins    in    Thrombo-angeitis     Obliterans,     with     Particular 

Reference  to  Arteriovenous  Anastomosis  as  a  Cure  for  the  Condition,  Jour. 

Amer.  Med.  Assoc.,  1900,  vol.  Hi,  1913. 
Carrel,  A.,   and  Guthrie,   C.   C. :     The   Reversal   of  the  Circulation    in   a   Limb, 

Annals  of  Surgery,  1906,  vol.  xliii. 

Coenen,  H.:    Miinch.  med.  Woch.,  1912,  Bd.  59,  No.  29. 
Coenen,  H.,  and  Wiewiorowski :    Ueber  das  Problem  der  Umkehr  des  Blutstromes 

und  die   Wietingsche  Operation,   Beit.   z.  klin.   Chir.,    1911,   Bd.   75,   Hft.    1 

and  2. 
Daviea,  H.  Morriston:     The  Value  of  Arteriovenous  Anastomosis  in  Gangrene  of 

the  Lower  Limb,  Annals  of  Surgery,  June,  1912,  p.  864. 
Glasstein:     Ueber  die  Behandlung  der  angiosklerotischen  Gangriin  der  untcn-n 

Extremitiit  mittels  arteriovenoser  Anastomose,   Berl.  klin.   Woch.,  No.   41, 

1911. 
Heyman:    Zur   Gefiisschirurgie,    Arterien-Venen-verbindung,    Deut.    med.    Woch., 

No.  34,  1911. 
Oppenheim:   Zur  Lehre  von  den  Neurovaskxiliiren  Erkrankungen,  Deut.   Zeit.  f. 

Nervenheilkunde,  Bd.  41,  Heft  4-6,  1911. 
Wieting,  Pasha:   Die  angiosclerotische  Gangriin  und  ihre  operative  Behandlung 

durch  Ueberleitung  des  arteriellen  Blutstromes  in  das  Venensystem,  Deut. 

Zeit.  f.  Chir.,  1911,  Bd.  110,  p.  364. 
Wieting,    Pasha:     Die    erfolgreiche    Behandlung    der    angiosklerotischen    ErTiiili- 

rungsstorungen   durch   die   Arteriovenose   Anastomose,   Deut.   Zeit.   f.   Chir., 

Nov.,  cxix,  Nos.  5  and  6,  pp.  369-590. 


CHAPTER  VII 

VARICOSE  VEINS 

VARICOSE  veins  are  usually  seen  in  the  lower  extremities 
in  adults,  although  they  may  occur  in  any  part  of  the  body. 
Many  causes  have  been  assigned  to  this  condition — obstruc- 
tion to  the  venous  return  from  pregnancy,  tumor  of  the  pelvis 
or  some  other  form  of  pressure,  cardiac  weakness,  congenital 
venous  defect,  etc., — but  whatever  may  be  its  origin  in  a  given 
case  there  is  a  gradual  but  progressive  valve  failure  in  the 
superficial  veins,  amounting  in  the  last  analysis  to  complete 
destruction  and  insufficiency.  Once  this  condition  has  arisen, 
it  can  be  cured  only  by  operation,  although  the  symptoms  can 
be  frequently  relieved  to  a  greater  or  lesser  extent  by  baths, 
change  of  occupation,  pressure  bandage,  and  a  number  of 
other  well-known  measures. 

The  operation  of  Schede,  and  its  modifications,  and  that 
of  Trendelenburg  and  its  modifications,  have  been  widely 
employed  and  have  been  followed  by  varying  measures  of 
success.  The  first  consists  in  a  division  by  partial  or  com- 
plete circular  incision  in  the  upper  third  of  the  leg  of  all  the 
superficial  veins,  including  the  long  and  short  saphenous, 
down  to  the  deep  aponeurosis.  Two  such  incisions  may  be 
made,  or  there  may  be  one  spiral  incision  circling  the  leg  two 
or  three  times,  according  to  the  various  modifications,  all  of 
which  have  for  their  purpose  the  division  of  the  superficial 
veins  of  the  limb  at  different  levels. 

Trendelenburg 's  operation,  consisting  of  division  and 
ligation  of  the  long  saphenous  at  the  point  of  junction  of  the 
lower  and  middle  thirds  of  the  thigh,  was  subsequently 
modified  by  its  author  by  ligating  the  saphenous  in  two  addi- 
tional places — just  above  the  internal  condyle  and  just  below 

61 


62  SURGERY  OF  THE  VASCULAR  SYSTEM 

the  knee.  The  vessel  is  exposed  through  small  incisions  at 
right  angles  to  its  course  and  ligated  between  two  ligatures, 
each  end  being  doubly  ligated.  The  operation  is  usually  per- 
formed under  local  anaesthesia. 

Better  than  either  Schede's  or  Trendelenburg's  operation 
is  the  method  of  resecting  the  offending  veins.  This  may 
be  either  partial  or  complete,  and  is  best  accompli  si  led  l>y 
two  incisions — one  extending  from  the  upper  end  of  the 
saphenous  vein  down  to  the  upper  limits  of  the  knee,  the 
other  extending  from  the  lower  limits  of  the  knee  down  to 
the  ankle,  or  as  far  as  the  varices  extend.  It  is  necessary  to 
interrupt  the  incision  at  the  knee  in  order  to  avoid  scar 
formation,  which  is  frequently  painful  and  might  cause  un- 
necessary functional  disturbance  of  the  joint.  The  vein  at 
the  knee  is  easily  removed  subcutaneously  by  working  down 
from  the  upper  incision  and  up  from  the  lower  incision.  If 
all  varices  cannot  be  removed  by  making  the  two  cardinal 
incisions,  as  outlined,  additional  incisions  must  be  resorted 
to.  The  operation  is  rather  a  formidable  one,  but  the  results 
justify  its  use  in  practically  all  cases  where  operation  is 
indicated. 

The  subcutaneous  method  of  removing  varicose  veins — 
by  means  of  a  vein  enucleator — as  suggested  by  C.  H.  Mayo 
in  1906  has  not  stood  the  test  of  time  and  need  only  be 
mentioned  in  passing. 

In  1906  Delbet  suggested  and  carried  out  an  operation, 
saphenofemoral  anastomosis,  by  which  he  proposed  to  relieve 
a  certain  group  of  varices  by  reimplantation  of  the  saphenous 
vein,  the  valves  of  which  have  become  incompetent,  into  the 
femoral  vein  at  a  site  10  or  12  cm.  lower  than  the  original 
and  normal  junction  and  below  one  or  more  sets  of  com- 
petent valves.  Delbet  reported  eight  cases,  and  at  the  German 
Surgical  Society  in  1911,  Hesse  and  Schaack  brought  the 
number  of  cases  up  to  forty-eight,  one  death  from  infection 


VARICOSE  VEINS  63 

having  occurred  in  their  own  series  of  twenty-three  cases, 
the  other  twenty-two  being  considered  cured,  although 
sufficient  time  had  hardly  elapsed  to  permit  of  any  such 
determination. 

It  is  not  my  intention  to  give  the  details  of  this  operation 
nor  to  discuss  its  theoretical  possibilities.  Those  interested 
may  refer  to  the  original  papers,  references  to  which  are 
appended.  I  do,  however,  wish  to  go  on  record  as  un- 
qualifiedly condemning  this  operation  as  a  pernicious  use  of 
the  blood-vessel  suture.  It  is  dangerous,  in  that  it  converts 
a  condition  that  in  the  great  majority  of  cases  can  be  relieved 
by  simple  and  practically  harmless  measures  into  one  that 
requires  for  its  relief  a  most  delicate  major  operation,  one 
that  in  unskilled  hands  will  most  certainly  be  followed  by 
dire  consequences.  So  far  as  I  am  aware  the  operation  has 
not  been  practised  in  this  country. 

Simple  ligation,  excision,  partial  or  complete — these  are 
measures  practically  devoid  of  danger,  and  as  the  condition 
itself  is  in  the  majority  of  cases  more  annoying  than  serious, 
it  seems  unnecessary  and  unwise  to  employ  a  difficult  and 
dangerous  operation  where  other  far  simpler  means  offer 
relief. 

REFERENCES 

Delbet,  P.:  Traitement  des  variees  par  1'anastomose  saphenofemorale,  Le  Bul- 
letin medical,  1900,  Xo.  99. 

Hesse,  E.,  and  Sehaack,  W. :  Die  sapheno-femorale  Anastomose,  eine  Ueberpflanz- 
ung  der  Vena  saphena  in  die  Vena  femoralis  nrittelst  Gefassnaht  als 
operative  Behandhmgs-methode  bei  Varicen,  Verhandlung  der  deutsche 
Gesellschaft  fur  Chirurgie,  1911,  Xo.  40,  p.  147.  Also  Annals  of  Surgery, 
1912,  vol.  Iv,  p.  170;  Arch.  f.  klin.  Chir.,  Bd.  59,  1911. 

Madelung:    Verhandl.  der  deutsch.  Gesellschaft  f.  Chir.,  1884. 

Mayo,  C.  H. :     Surgery,  Gynaecology,  and  Obstetrics,   1906. 

Miller,  R.  T.:    Bull.  Johns  Hopkins  Hosp.,  Sept.,  1906. 

Schede,  M.:    Arch.  f.  klin.  Chir..  Bd.  43,  1892. 

Trendelenburg:    Beitriige  zur  klin.  Chir.,  Bd.  58,  1908. 


CHAPTER  VIII 

SURGERY  OF   THE  HEART 

SURGERY  of  the  heart  consists  chiefly  in  attempting  to 
suture  bullet  and  stab  wounds,  accidental  or  self-inflicted, 
although  there  is  an  increasing  number  of  recorded  cases  of 
pericardiotomy — drainage  of  the  pericardium — and  of  cardio- 
lysis — resection  of  the  ribs  overlying  an  adherent  pericardium. 

Coincident  with  the  advance  of  surgical  teclmic,  there 
has  been  a  gratifying  increase  in  the  self-confidence  of  the 
modern  surgeon,  so  that  those  individuals  unfortunate  enough 
to  receive  an  injury  to  the  heart  now  have  a  pretty  fair 
chance  for  life — provided  they  live  long  enough  to  be  b rough  t 
to  a  well-equipped  hospital.  The  usual  method  in  such  n 
case,  a  proper  diagnosis  having  been  made,  or,  when  this  is 
impossible,  signs  and  symptoms  sufficient  to  warrant  explora- 
tion having  been  obtained,  is  hurriedly  but  freely  to  expose 
the  heart  either  by  resecting  the  two  or  three  ribs  overly  inir 
it  or  by  making  a  trap-door  exposure.  If  the  pleura  has  not 
been  wounded  it  should  be  displaced  outward.  The  peri- 
cardium is  opened  by  a  longitudinal  incision,  the  heart  is 
grasped  by  the  left  hand  and  lifted  out,  the  tip  of  a  finger 
being  placed  over  any  wound  that  may  be  encountered  in 
order  to  control  bleeding.  With  a  large,  round,  curved 
needle,  threaded  with  catgut  (silk,  too,  may  be  used),  the 
wound  is  closed  either  by  a  simple  through-and-through  con- 
tinuous stitch  or  by  several  interrupted  stitches,  after  which, 
all  blood  having  been  removed  from  the  pericardial  cavity, 
the  heart  is  carefully  replaced  in  its  bed. 

In  a  paper  on  "Experimental  Surgery  of  the  Mitral 
Valve,"  written  in  1909,  I  remarked  that  it  seemed  to  me 
more  conservative  never  to  close  completely  the  pericardium 

64 


SURGERY  OF  THE  HEART  65 

after  it  had  been  opened  to  suture  a  wound  of  the  heart.  A 
small  opening  left  at  the  most  dependant  part  of  the  in- 
cision would  take  care  of  any  little  ooze  or  leakage  that  might 
occur,  which  in  a  closed  sac  might  seriously  embarrass  the 
heart  action.  I  still  hold  to  this  opinion  to  the  extent  of 
advising  that  its  adoption  as  a  rule  might  in  the  great  ma- 
jority of  instances  obviate  the  necessity  of  inserting  a  drain 
in  the  pericardium;  any  collection  of  fluid,  pus,  serum,  or 
blood  would  be  forced  out  into  the  pleural  cavity  or,  if  this  is 
intact,  into  the  tissues  beneath  the  incision,  where  signs  of 
its  presence  would  soon  be  given. 

In  cases  where  the  patient  is  exsanguinated  and  in  col- 
lapse, an  intravenous  infusion  of  warm  salt  solution  should 
be  started  while  the  preparations  for  operation  are  in 
progress.  As  a  last  resort  direct  transfusion  of  blood  may 
be  given  either  during  the  course  of  the  operation  or  imme- 
diately upon  its  conclusion. 

It  is  probable  that  many  unsuccessful  attempts  to  suture 
heart  wounds  are  never  reported;  therefore  any  statistics 
that  may  be  given  must  not  be  accepted  too  literally.  Rehn 
in  1907  collected  and  reported  124  cases  with  49  recoveries 
(39.5  per  cent.)  and  75  deaths  (60.5  per  cent.).  Of  the  75 
fatalities,  16  died  on  the  operating  table,  17  died  from  loss 
of  blood  and  collapse  within  two  days,  30  died  of  infection- 
purulent  pericarditis  and  empyema.  In  many  cases  the 
urgency  of  the  case  prevented  disinfection  of  the  field — a 
difficulty  that  the  iodine  technic  should  overcome  in  future 
cases.  One  patient  (Cferzen's)  died  of  sudden  hemorrhage 
on  the  fifty-third  day. 

Statistics  later  than  those  of  Rehn's  are  those  reported 
by  Hesse,  who  gives  219  cases  with  103  recoveries  (47  per 
cent.)  and  106  deaths  (53  per  cent.),  and  of  Simon,  who  re- 
ports 241  cases  with  117  recoveries  (49  per  cent.)  and  124 
5 


66  SURGERY  OF  THE  VASCULAR  SYSTEM 

deaths  (51  per  cent.).  It  will  thus  be  seen  that  the  number 
of  cases  saved  is  gratifyingly  large. 

Cardiolysis  is  an  operation  that  was  introduced  in  1902 
by  Brauer  of  Heidelberg  for  the  relief  of  adherent  peri- 
cardium. It  consists  of  a  subperio steal  resection  of  the  pre- 
cordial  ribs,  to  the  under  surface  of  which  the  pericardium  is 
adherent.  A  number  of  successful  cases  have  been  reported 
not  only  by  Brauer  but  by  others,  and  this  simple  method  of 
treatment  promises  to  revolutionize  the  therapy  of  adherent 
pericardium. 

According  to  Hirschf elder,  "As  regards  the  indications 
for  cardiolysis,  it  would  appear  that  since  the  adherent  peri- 
cardium cannot  otherwise  be  relieved,  this  operation  is 
worthy  of  trial  whenever  symptoms  of  cardiac  weakness 
occur  and  recur  in  a  patient  with  well-marked  adhesions  to 
chest  wall  (tugging  in  of  the  lower  ribs,  fixation  of  the  left 
border  of  flatness  on  inspiration,  immobility  of  the  apex) 
and  recur  in  spite  of  general  cardiac  hygiene." 

Pericardiotomy  is  an  operation  in  which  the  pericardium 
is  freely  opened  and  drained,  and  is  most  frequently  resorted 
to  for  purulent  effusions,  although  it  may  be  required  to 
relieve  a  simple  serous  ha?mo-  or  pneumopericardium.  Ex- 
posure of  the  pericardium  is  usually  obtained  by  resecting 
close  to  the  sternum  the  fourth,  fifth,  and  sixth  costal  car- 
tilages; sometimes  a  satisfactory  exposure  will  be  obtained 
by  resecting  only  one  costal  cartilage,  while  in  other  instances 
two  or  even  all  three  will  have  to  be  removed.  The  chief 
dangers  are  wounding  of  the  internal  mammary  artery  and 
entering  the  pleural  cavity,  accidents  that  can  be  avoided  by 
careful  work  in  the  vast  majority  of  cases.  The  opened  peri- 
cardium should  be  thoroughly  irrigated  with  warm  salt 
solution,  the  operation  being  performed  under  light  anaes- 
thesia. A  soft  rubber  tube  or  protective  wick  should  be  left 


SURGERY  OF  THE  HEART  67 

to  drain  the  pericardium  and  the  whole  wound  should  remain 
open  in  order  that  further  irrigation  may  be  instituted  should 
necessity  arise. 

REFERENCES 

Bernheim,   B.  M. :    Experimental   Surgery  of  the  Mitral  Valve,  Johns  Hopkins 

Hosp.  Bull.,  1909,  vol.  xx,  107. 
Brauer,  L.:     Cardialyse,  Miinchen.  med.  Woch.,   1902,  Bd.  49,  982.     Untersuch- 

ungen   an   herzen   Cardiolysis   und   ihre   Indikationen,   Arch.   f.   klin.   Chir., 

Berl.,  1903,  Bd.  71,  258. 
Delatour,  A.   B. :     Surgery  of  the   Pericardium  and  Heart,  Am.  Jour.   Surgery, 

1909. 
Delorme,   E.,  and  Mignon:     Sur  la  ponction   et  incision   du   pericarde,   Rev.   de 

Chir.,  Par.,  1895,  vol.  xv,  pp.  797,  987,  and  1896,  vol.  xvi,  p.  56. 
Hesse,  Erich:    Beitr.  z.  klin.  Chir.,  Bd.  75,  Heft  3. 
Hirschfelder,  A.  D.:    Diseases  of  the  Heart  and  Aorta,  1912. 
Rehn,  L. :    Zur  Chirurgie  des  Herzens  und  des  Herzbeutals,  Arch.  f.  klin.  Chir., 

1907,  Bd.  83,  723. 
Simon:      Ueber    Schusverletzungen   des    Herzens,    Deut.    Zeit.    f.    Chir.,    Bd.    115, 

Heft  3-4. 
Wagner,    A.:     Beitrag   zur    Chirurgie    des    Herzens,    Deut.    Zeit.    f.    Chir.,    1912, 

Bd.  119. 
Mitchell,  Charles  F. :   Stab- wound  of  the  Heart;   Recovery  after  Suture,  Annals 

of  Surgery,  Feb.,  1913,  p.  296. 
Konig:    Technic  for  Access  to  Suture  of  the  Heart,  Deut.  Zeit.  f.  Chir.,  vol.  cxii, 

Nos.  4  and  6. 
Poole:    Annals  of  Surgery,  April,  1912. 


CHAPTER  IX 

ANEURISMS 

THERE  are  several  different  methods  of  dealing  with 
aneurisms,  speaking  generally,  and  I  shall  take  up,  in  detail, 
those  that  have  given  the  best  results.  Before  opening  the 
subject,  I  wish  to  call  the  attention  of  the  reader  to  the  fact 
that,  due  to  anatomical  conditions,  in  certain  regions  of  the 
body  there  is  little  or  no  choice  of  operation;  in  others,  there 
is  a  very  wide  choice,  and  the  success  or  failure  of  the  pro- 
cedure may  depend  on  the  type  of  operation  selected.  For 
example,  aneurisms  involving  the  arch  of  the  aorta  lend  them- 
selves to  practically  but  one  form  of  surgical  interference- 
wiring — while  those  involving  the  popliteal  artery  may  he 
treated  by  any  one  of  several  different  methods — simple 
ligation,  endo-aneurismorrhaphy,  excision,  extirpation  and 
arterial  suture,  etc.  Aneurisms  of  the  abdominal  aorta  are 
usually  best  handled  by  wiring,  especially  those  occurring 
above  the  renal  vessels,  but  Halsted's  aluminum  band  has 
been  successfully  applied,  and  actual  ligation  of  the  aorta  has 
been  performed.  Arterial  suture  may  possibly  be  of  service 
here  provided  the  aneurism  is  of  such  size  and  position  that 
it  can  be  excised.  It  is  a  question  as  to  whether  Matas's  endo- 
aneurismorrhaphy  will  ever  be  successfully  applied  to  the 
aorta,  although  it  should  always  be  kept  in  mind.  On  the 
other  hand  there  is  little  or  no  choice  when  it  comes  to 
handling  aneurisms  involving  the  great  vessels  at  the  root  of 
the  neck.  Halsted's  band  has  a  certain  usefulness,  and  it  is 
possible  that  Matas's  operation  may  be  of  limited  service, 
but  in  the  great  majority  of  cases  simple  ligation  is  the  only 
measure  that  offers  the  slightest  hope  of  success,  and  this  is 

68 


ANEURISMS  69 

often  as  difficult  and  delicate  and  dangerous  a  piece  of  work 
as  falls  to  the  lot  of  the  surgeon. 

It  is  unnecessary  to  devote  a  special  section  to  the  method 
of  extirpating  an  aneurism  or  of  ligating  an  artery.  The 
application  of  general  surgical  principles  is  all  that  is  re- 
quired, care  being  exercised  to  obtain  a  proper  exposure.  In 
the  tying  of  all  vessels,  two  ligatures  are  commonly  used; 
these  should  be  separated  by  an  interval  of  from  a  quarter 
to  half  an  inch.  Both  ligatures  should  be  of  heavy  ma- 
terial so  as  to  minimize  as  much  as  possible  the  liability  of 
cutting  through  the  vessel  wall  and  consequent  hemorrhage. 
Kangaroo  tendon  is  an  excellent  material — it  is  heavy,  strong 
and  has  the  very  slight  degree  of  elasticity  that  is  greatly  to 
be  desired. 

The  following  methods,  then,  of  dealing  with  aneurisms 
will  be  described:  (1)  Matas's  endo-aneurismorrhaphy;  (2) 
the  Moore-Corradi  wiring  operation;  (3)  Halsted's  method 
of  gradual  occlusion. 

ENDO-ANEURISMORRHAPHY    (  MATAS  ) 

This  operation — commonly  known  as  the  "Matas  opera- 
tion"—was  first  practised  by  its  author  on  March  30,  1888, 
the  patient  being  a  man  who  was  suffering  from  an  aneurism 
of  the  brachial  artery  that  had  resisted  proximal  and  distal 
ligature.  Success  crowned  Matas's  effort,  and  the  operation 
as  it  has  been  developed  has  come  to  be  one  that  can  be  relied 
upon  to  give  constant  results  in  a  class  of  cases  which 
formerly  tried  the  patience  and  resources  of  both  patient 
and  surgeon,  and  not  infrequently  ended  in  the  crippling  or 
destruction  of  the  former. 

The  method  comprises  two  separate  and  distinct  forms 
of  operation,  the  choice  of  one  of  these  being  entirely  depend- 
ent on  the  type  of  aneurism  under  consideration.  The  first 


70  SURGERY  OF  THE  VASCULAR  SYSTEM 

and  most  widely  used  form,  the  obliterative  endo-aneurismor- 
rhaphy,  is  used  "in  those  aneurisms  in  which  the  parent 
artery  is  entirely  lost  at  the  site  of  the  aneurism  by  expand- 
ing into  the  aneurismal  sac  throughout  its  circumference; 
also  those  in  which  the  friability  or  diseased  state  of  the 
sac  wall  is  such  as  to  preclude  all  possible  use  as  plastic 
material  (atheroma,  calcareous  degeneration).  In  these 
cases  there  are  always  two  orifices  within  the  sac  separated 
by  variable  intervals,  and  there  is  no  visible  outline  of  the 
main  artery  in  the  interior  of  the  sac.  Except  in  unusual 
conditions  no  attempt  is  made  to  restore  the  continuity  of 
the  parent  artery;  the  blood  stream  is  interrupted  in  that 
part  of  the  vessel  which  directly  opens  into  the  sac,  and  the 
arterial  orifices  are  simply  closed  by  suture,  thus  shutting 
off  the  sac  cavity  from  all  visible  source>s  of  blood  supply." 

The  second  form,  the  restorative  or  reconstructive  endo- 
aneurismorrhaphy,  has  a  more  limited  field  of  usefulness  in 
that  it  is  only  indicated  in  definite  saccular  aneurisms,  or 
those  in  which  there  is  a  "well-defined  and  deep  furrow  or 
gutter  leading  from  the  inlet  to  the  outlet  of  the  sac.  This 
deep  groove  or  fissure  furnishes  the  outline  of  the  parent 
artery,  which  is  easily  restored  without  obliterating  the 
main  channel." 

In  the  obliterative  type  of  operation,  after  all  pulsation 
and  bleeding  into  the  sac  has  been  absolutely  controlled  by 
temporary  ligatures  or  the  application  of  Crile  clamps  to 
the  vessels  outside  the  aneurism,  a  longitudinal  incision  is 
made  through  the  wall  of  the  sac,  so  as  thoroughly  to  ex- 
pose all  visible  orifices  within  it.  If  any  loosely  adherent 
clots  are  present,  as  they  usually  are,  they  should  be  care- 
fully wiped  out,  after  which  all  orifices  are  closed  (Fig.  50) 
by  rather  deep  interrupted  or  continuous  sutures  of  chromic 
catgut,  No.  1,  2  or  3,  according  to  the  size  of  the  aneurism, 


ANEURISMS 


71 


threaded  on  half  or  full-curved  round  needles.  The  cavity 
of  the  sac  is  then  totally  obliterated  by  rows  of  sutures 
placed  in  its  walls.  This  is  occasionally  difficult  to  accom- 
plish because  of  the  frequent  large  size  of  the  cavity,  the 
thickness  of  the  sac  wall,  and  the  general  density  of  the 
surrounding  tissues,  but  by  taking  advantage  of  the  natural 


FIG.  50. — Obliterative  endo-aneurismorrha- 
phy  (Matas).  Orifices  in  aneurismal  sac  being 
obliterated  by  suture,  when  restoration  or  recon- 
struction of  arterial  channel  is  impracticable. 
(Keen's  Surgery,  vol.  v.) 


FIG.  51. — Restorative  endo-aneurismor- 
rhaphy  (Matas)  applied  to  sacculated  aneu- 
risms with  a  single  orifice  of  communication. 
Orifice  being  closed  by  continuous  suture, 
without  obliterating  parent  artery.  (Keen's 
Surgery,  vol.  v.) 


folds  in  the  sac  wall  and  by  the  exercise  of  a  bit  of  ingenuity, 
it  can  nearly  always  be  accomplished  without  infolding 
sliding  skin  flaps,  a  method  to  which  one  must  resort  very 
occasionally.  Emphasis  is  laid  upon  this  point  because  it 
is  always  unwise  to  drain  an  unruptured,  uninfected  aneu- 
rismal cavity.  In  those  that  are  ruptured  or  infected  at  the 


72 


time  of  operation,  drainage  and  healing  by  granulation 
should  be  the  method  of  choice,  rather  than  any  attempt  to 
obliterate. the  cavity. 

In  the  restorative  or  reconstructive  form  of  endo-aneu- 
rismorrhaphy,  after  opening  the  sac  an  attempt  is  made  to 
close  off  the  parent  artery  (Fig.  51)  from  the  sac  without 

obliterating  the  lumen  of  the 
artery  (Fig.  52).  Where  the 
aneurism  is  of  the  purely  sac- 
cular  variety,  and  there  is  only 
one  small  opening  into  the  side 
of  the  artery,  it  is  a  rather 
simple  affair  to  close  this  off  by 
interrupted  or  continuous  sut- 
ures of  No.  0  to  00  chromic  cat- 
gut threaded  on  small  curved 
needles. 

But  where  a  furrow  running 
through  the  floor  of  the  aneurism 
is  all  that  remains  of  the  parent 
artery,  conditions  are  altered  and 
it  is  a  difficult  matter  to  recon- 
struct the  vessel.  The  use  of  a 
catheter,  placed  in  the  bed  of  the 
vessel,  as  a  guide  in  suturing 
facilitates  matters,  but  it  would 
seem  best  in  cases  where  there 
is  extreme  need  for  the  preser- 
vation of  circulation  through  the  main  channel  to  perform 
an  arterial  or  venous  transplantation  after  complete  excision 
of  the  aneurism. 

After  restoration  or  reconstruction  of  the  artery  the 
cavity  of  the  sac  is  obliterated  in  the  usual  way,  great  care 
being  used  to  make  it  complete  and  absolute. 


FIG.  52.  —  Restorative  endo-aneuris- 
morrhaphy  (Matas).  Aneurismal  sac 
closed  off  from  parent  artery.  (Keen's 
Surgery,  vol.  v.) 


ANEURISMS  73 

The  chief  advantages  of  the  Matas  operation  over  other 
forms  are : 

(1)  The   collateral   circulation   of   the   extremity   is.  left 
practically  undisturbed. 

(2)  There  is  very  little  danger  of  injuring  the  parent 
vein — a  real  danger  in  extirpation  and  one  markedly  increas- 
ing the  danger  of  gangrene. 

(3)  The    parent    artery    is    obliterated    over    the    least 
possible  extent. 

Statistically  Matas  reported  in  1908  the  following:1 

85  cases  operated  by  52  surgeons 

59  were  of  the  obliterative  type  (69  per  cent.) 

26  were  of  the  restorative  or  reconstructive  type  (30.8  per  cent.) 

Recoveries 78 

Deaths 7 

Gangrene 4 

Relapses — , 4 

All  reconstructive  cases 

Secondary  hemorrhage 2 

WIRING 

This  operation,  which  is  only  indicated  in  certain  forms 
of  thoracic  and  abdominal  aneurisms  otherwise  necessarily 
inoperable,  was  devised  in  1864  by  Moore,  of  London,  and 
subsequently  modified  by  Corradi,  the  procedure  being  at 
present  known  as  the  Moore-Corradi  method  of  wiring 
aneurisms. 

According  to  Dr.  John  M.  T.  Finney,  who  has  probably 
had  a  wider  experience  with  this  method  of  treating 
aneurisms  than  any  one  else  in  this  country,  all  that  is  neces- 
sary as  regards  technic  is  a  hollow  needle  not  too  large  in 
size,  insulated  with  the  best  quality  of  French  lacquer  to 
within  a  short  distance  of  its  point.  Through  this  a  wire 
made  from  a  silver  and  copper  alloy  (Hunner)  in  the  pro- 
portion of  75  parts  copper  to  1000  parts  silver  is  passed. 

1  For  detailed  statistics  see  Keen's  Surgery,  vol.  v,  pp.  279  and  280. 


74  SURGERY  OF  THE  VASCULAR  SYSTEM 

The  wire  should  be  previously  wound  tightly  upon  a  wooden 
spool  in  order  to  give  it  a  coil,  and  care  should  be  taken  to 
avoid  kinking,  as  this  interferes  with  its  passage  through 
the  needle. 

After  the  skin  has  been  cocainized  (supposing  a  thoracic 
aneurism  is  to  be  treated)  and  drawn  to  one  side,  the  needle 
is  inserted  slowly  until  the  arterial  blood  appears  in  jets 
through  its  lumen.  The  end  of  the  wire  which  has  been 
previously  passed  into  the  needle,  but  not  so  far  as  the  point, 
is  now  passed  directly  into  the  aneurism  until  the  amount 
wound  upon  the  spool  has  been  introduced  into  the  aneurismal 
cavity.  This  amount  is  arbitrarily  chosen  to  be  ten  feet. 
Freeman  and  some  others  hold  the  opinion  that  the  greater 
the  amount  of  wire  introduced  into  the  sac  the  better,  but 
the  prevailing  objection  to  this  view  is  that  it  prevents  the 
contraction  of  the  resulting  clot  in  the  course  of  its  subse- 
quent organization. 

If  the  needle  is  not  well  insulated,  or  if  it  is  pushed  so 
far  into  the  aneurismal  sac  that  its  non-insulated  shoulder 
comes  in  contact  with  the  skin,  there  is  danger  that  an 
electrolytic  burn  may  result  along  the  needle's  track.  The 
consequent  slough  decreases  the  strength  of  the  aneurismal 
wall  and  is  likely  to  cause  leaking  at  that  point.  Hare,  who 
also  has  had  considerable  experience  with  the  wiring  opera- 
tion, calls  particular  attention  to  the  necessity  for  care  in 
this  detail. 

With  the  positive  pole  attached  to  the  wire  and  the 
negative  pole  at  the  patient's  back,  the  current  is  gradually 
turned  on,  the  routine  being  10  milliamperes  for  the  first 
ten  minutes,  20  ma.  for  the  second  ten  minutes,  30  ma.  for 
the  third  ten  minutes,  and  so  on  until  about  70  or  80  ma. 
have  been  attained;  then  the  current  is  reduced  by  the  same 
succession  of  intervals  by  which  it  was  advanced,  the  whole 
procedure  lasting  from  one  to  one  and  a  half  or  even  two 


ANEURISMS  75 

hours.  After  the  current  has  been  passed  through  the 
aneurism  for  the  given  time,  the  needle  should  be  carefully 
withdrawn  with  a  slight  rotary  motion,  not  disturbing  the 
wire,  which  is,  of  course,  left  in  the  sac.  When  the  needle 
is  entirely  withdrawn  the  wire  is  cut  as  short  as  possible, 
depressing  the  skin  with  the  point  of  the  blunt  scissors.  The 
skin  should  then  be  pinched  up  with  the  fingers,  until  the 
end  of  the  wire  is  completely  buried  beneath  its  entire  thick- 
ness, and  if  the  precaution  of  drawing  the  skin  to  one  side 
before  insertion  of  the  needle  has  been  taken,  as  suggested, 
the  end  of  the  wire  will  not  remain  opposite  the  skin  puncture. 
This  seems  a  small  point,  but  it  is  important  in  order  to 
prevent  a  certain  amount  of  irritation  and  the  possibility 
of  infection  extending  down  along  the  course  of  the  wire. 
Pressure  over  the  wound  should  be  applied  immediately  upon 
the  withdrawal  of  the  needle,  in  order  to  prevent  the  forma- 
tion of  a  haematoma  due  to  the  escape  of  blood  into  the  sub- 
cutaneous tissue. 

In  the  case  of  aneurisms  of  the  abdominal  aorta,  it  is  of 
course  necessary  to  open  the  abdomen  and  expose  the  aneu- 
rismal  sac,  at  least  in  part,  before  insertion  of  the  needle. 
For  the  manipulations  within  the  peritoneal  cavity>  it  is 
usually  necessary  to  give  a  few  whiffs  of  ether,  but  the  pa- 
tient is  allowed  to  come  out  of  the  anaesthesia  and  remain 
conscious  during  the  entire  time  "that  the  current  is  running, 
the  abdominal  contents  being  packed  off  so  as  to  allow  the 
needle  to  protrude.  Ether  may  again  be  necessary  in  closing 
the  peritoneum,  but  if  morphine  has  been  judiciously  used 
very  little  will  be  required. 

The  immediate  risks  of  the  operation,  especially  in 
aneurism  of  the  thoracic  aorta,  are  not  great.  They  consist 
in  the  possibility  of  an  end  or  loop  of  the  wire  sliding  along 
the  wall  of  the  aorta  in  the  direction  of  the  heart  and  inter- 
fering with  the  action  of  its  valves  (its  presence  in  the  aorta 


76  SURGERY  OF  THE  VASCULAR  SYSTEM 

giving  rise  to  no  symptoms),  or  in  the  formation  of  emboii 
which  may  be  swept  off  by  the  blood  current.  These  com- 
plications have  occurred  only  in  rare  instances.  In  a  case 
treated  by  Pasham  a  loop  of  wire  entered  the  cavity  of  the 
heart  without  fatal  result,  the  condition  being  found  acci- 
dentally at  autopsy  some  time  after  wiring.  In  another  in- 
stance an  embolus  necessitated  amputation  of  an  arm,  but 
since  the  patient's  aneurism  was  cured  he  was  content,  saying 
"that  he  would  rather  have  one  arm  and  no  aneurism  than 
two  arms  with  an  aneurism." 

The  remote  risks  arise  from  emboii  or  sloughing  due  to 
a  too  strong  current,  sepsis,  and  from  rupture  of  the 
aneurismal  wall,  due  to  the  shunting  of  the  blood  current  by 
the  new-formed  clot  against  another  portion  of  the  aneu- 
rismal sac.  With  the  possible  exception  of  the  last-mentioned 
risk,  others  in  this  advanced  day  are  apparently  negligible. 

The  immediate  benefits  of  this  operation  are  most  striking. 
Perhaps  the  most  remarkable  of  all  is  the  diminution  of  pain, 
which  often  begins  before  the  operation  is  finished.  In  a 
number  of  instances,  the  patient  while  still  on  the  operating 
table  has  stated  that  the  pain  was  appreciably  decreasing. 
From  this  encouraging  result  one  is  justified  in  promising 
the  patient  a  marked  relief  from  pain,  even  if  no  other  benefit 
is  derived;  and  frequently  one  can  guarantee  a  diminution  of 
the  dyspnrea,  sometimes  so  pronounced  in  advanced  cases. 

As  a  rule  the  hardening  of  the  clot  as  shown  by  the  lessen- 
ing or  disappearance  of  expansile  pulsation  does  not  take 
place  for  some  days  or  even  weeks,  but  immediate  marked 
diminution  in  the  pulsation  of  the  tumor  has  been  observed 
in  a  number  of  cases.  Complete  rest  in  bed  for  a  term  of 
weeks  or  even  months  after  the  wiring  is  an  absolute  necessity 
for  the  success  of  the  procedure,  and  it  is  often  difficult  to 
restrain  the  patient  who  feels  so  well  two  or  three  weeks  after 


ANEURISMS  77 

the  operation.  Hirschfelder  especially  lays  emphasis  on  the 
need  for  bodily  and  mental  rest,  and  suggests  that  the  ad- 
ministration of  calcium  salts  both  before  and  after  the  opera- 
tion might  be  of  advantage.  He  further  says  that,  "  .  .  .  the 
treatment  (preliminary  and  post-operative)  is  quite  as  im- 
portant as  the  operation  itself.  In  justice  to  both  himself 
and  the  patient,  the  surgeon  should,  before  undertaking  the 
case,  insist  that  the  patient  consent  to  remain  under  treat- 
ment and  absolute  rest  for  from  three  to  five  months,  at  least 
a  month  of  which  should  precede  the  operation,  and  at  least 
another  month  should  elapse  after  the  last  trace  of  expansile 
pulsation  has  been  felt  in  the  tumor.  Only  threatened  rup- 
ture of  the  aneurism  or  intolerable  symptoms  justify  an 
operation  without  prolonged  preliminary  treatment." 

Finney2  reported  twenty-three  personal  cases,  of  which 
only  two  were  alive  at  the  time  of  the  report,  one  nearly  three 
years,  the  other  not  quite  one  year  after  the  operation.  All 
patients  were  men,  mostly  young  men,  only  two  being  over 
fifty  years  of  age.  One-half  gave  a  history  of  lues,  and  one, 
who  denied  it,  had  a  positive  Wasserinann.  Over  25  per  cent, 
admitted  the  excessive  use  of  alcohol.  In  three  instances  the 
trouble  was  apparently  of  traumatic  origin. 

There  is  little  to  be  hoped  for  in  the  way  of  permanent 
cure  by  this  operation.  The  condition  is  always  desperate 
and  with  few  exceptions  absolutely  hopeless  from  the  outset. 
But  when  one  takes  into  consideration  the  prompt,  almost 
constant,  marvellous  relief  from  that  terrific  pain  so  uni- 
formly suffered  by  individuals  afflicted  with  aortic  aneurism, 
the  almost  certain  prolongation  of  life — frequently  extending 
over  months  and  years,  during  which  time  the  patient  is  up 
and  about — and  the  utter  hopelessness  for  the  patient  under 

2  Since  his  original  report.  Dr.  Finney  has  wired  an  additional  number  of 
cases,  the  results  of  which  have  been  extremely  gratifying. 


78  SURGERY  OF  THE  VASCULAR  SYSTEM 

any  other  form  of  treatment,  it  is  evident  that  wiring  is  a 
justifiable  operation  in  every  case  of  abdominal  and  thoracic 
aneurism  where  it  is  not  especially  contraindicated. 


It  has  been  a  recognized  fact  for  years  that  if  the  parent 
vessel  of  an  aneurism  could  be  occluded  by  some  process 
slow  enough  to  permit  a  concomitant  development  of  satis- 
factory collaterals,  a  great  step  forward  in  the  treatment  of 
this  condition  would  have  been  taken.  Many  surgeons  have 
worked  on  the  subject,  always  a  fascinating  one,  and  numer- 
ous methods  have  been  suggested  and  tried  out,  only  to  be 
discarded  later  on  as  worthless.  The  method  devised  by 
Professor  Halsted  in  1905,  and  practised  since  then  by  him 
and  others,  has  stood  the  test  of  time  and  has  proved  to  be 
of  undoubted  value  in  certain  forms  of  aneurism.  Jt  consists, 
in  brief,  in  partially  constricting  the  vessel  by  means  of  an 
aluminum  band  rolled  around  the  vessel  by  means  of  an  in- 
strument specially  constructed  for  that  purpose,  the  idea 
being  that,  ''When  the  lumen  had  been,  perhaps,  not  quite 
occluded,  complete  obliteration  might  result  spontaneously 
with  the  conversion  of  the  arterial  wall  embraced  by  the  band 
into  a  solid  cylinder  of  living  tissue.  This  may  be  considered 
the  ideal  closure  of  an  artery." 

The  aluminum  used  varies  in  thickness  from  No.  25  to 
No.  46  (American  scale),  the  finer  numbers  being  used  on 
small  vessels,  the  heavier  on  larger  ones  like  the  aorta.  For 
the  common  carotid  of  the  human,  No.  33  does  very  well, 
while  perhaps  No.  35  or  No.  36  would  be  better  for  the  aorta. 
Coming  as  it  does  in  sheets,  the  metal  is  cut  in  strips  to  fit 
the  band  roller,  the  length  of  the  strip  being  about  that  of 
the  circumference  of  the  full  artery,  the  width  varying  accord- 
ingly, being  about  1  cm.  for  the  thoracic  aorta  and  innominate 


ANEURISMS 


79 


artery  in  man.  The  distal  end  must  be  rounded  and  "mani- 
cured" with  a  nail  file  to  facilitate  coiling;  the  edges  are 
simply  smoothed  and  the  proximal  end  is  left  square.  If 
these  precautions  are  taken  and  the  aluminum  sterilized  only 
once — repeated  boilings  render  it  too  brittle  for  perfect  roll- 
ing— there  is  practically  no  danger  of  a  vessel  cutting  itself 
on  the  band,  unless  it  is  markedly  sclerosed  and  brittle — in 
which  case  the  band  had  best  not  be  used  at  all. 


FIG.  53. — A,  Halsted's  original  band  roller  in  the  act  of  curling  a  metal  strip  about  an  artery; 
B,  the  improved  band  roller  about  to  expel  a  band. 

The  band  roller  is  so  beautifully  illustrated  that  a  detailed 
description  is  superfluous  (Fig.  53,  A  and  B).  It  is  enough 
to  say  that  the  band,  all  properly  cut  and  manicured,  is 
' '  loaded ' '  into  the  instrument  and  is  curled  around  the  artery 
by  means  of  a  piston  or  driving-rod,  the  instrument  being 
gradually  withdrawn  as  the  curling  proceeds.  "The  band 
should  be  long  enough  to  encircle  the  artery  in  its  expanded 
state  and  the  metal  should  be  sufficiently  thick  and  wide  to 
sustain  the  curl  given  it  by  the  instrument.  If  perfectly 


80  SURGERY  OF  THE  VASCULAR  SYSTEM 

rolled,  the  inside  and  outside  circles  of  the  metal  (there  are 
usually  about  one  and  one-half  or  two  circles)  touch  cadi 
other  at  all  points  of  the  surfaces  of  contact  and,  in  con- 
sequence, the  cohesion  force  is  greatest." 

Experience  must  determine  the  degree  to  which  a  vessel 
should  be  occluded,  although  one  may  make  the  general  state- 
ment that  if  after  the  rolling  instrument  has  been  removed, 
there  is  any  pulsation  below  the  site  of  occlusion,  the  band 
should  be  carefully  tightened  up  by  a  gentle  coiling  motion 
of  the  thumb  and  first  finger  until  pulsation  is  imperceptible. 
This  is,  of  course,  perfectly  possible  without  complete  stop- 
page of  the  blood  flow. 

REFERENCES 

Finney,  J.  M.  T. :     The  Wiring  of  Otherwise  Inoperable  Aneurisms,  Annals  of 

Surgery,  May,  1912,  p.  661. 

Freeman,  L. :    Transactions  of  the  Amer.  Surg.  Assoc.,  vol.  xix,  1901. 
Halsted,  W.  S. :    Partial,  Progressive  and  Complete  Occlusion  of  the  Aorta  and 

Other  Large  Arteries  in  the  Dog  by  Means  of  the  Metal  Band.  Jour.  Exper. 

Medicine,  1909,  vol.  xi,  p.  373. 

Hare,  H.  A.:    Therap.  Gazette,  1900,  1903,  and  1905,  July,  p.  433. 
Hirschfelder,  A.  D. :    Diseases  of  the  Heart  and  Aorta,  Lippincott,  1912. 
Lusk,  W.   C. :     The  Treatment  of  Large  Aneurisms  with   Gold   Wire  and   Klec- 

trolysis,  with  Report  of  a  Case:  Experimental  Results,  Transac.  of  the  Xt-\v 

York  Surg.  Soc.,  April  27,  1910. 
Matas:    Keen's  Surgery,  vol.  v. 


STATISTICAL,  STUDY  OF  THE  TREATMENT  OF  ANEURISMS 

MOST  of  the  recent  statistical  studies  on  the  treatment  of 
aneurisms  have  failed  of  practical  satisfaction  because,  for 
the  greater  part,  they  have  been  incomplete  and  practically 
all  have  dealt  with  the  affection  in  a  single  vessel  and  by  a 
single  method  of  treatment.  These  studies  have  reviewed 
the  field  from  the  early  days  of  pre-antiseptic  surgery  and 
have  compared  the  results  of  the  last  half  century  with  those 
of  to-day — an  interesting  but  not  practically  profitable  survey. 

It  has  seemed  best  to  me,  therefore,  to  include  in  this 
chapter  an  analytical  study  of  modern  methods  and  present- 
day  results  in  such  form  that  it  can  be  of  immediate  practical 
help.  For  example,  the  surgeon  who  has  in  charge  a  case  of 
aneurism  of  the  subclavian  artery  or  the  femoral  artery  or 
any  of  the  larger  vessels  can  by  the  use  of  the  tables  which 
follow  ascertain  at  once  the  statistics  as  to  mortality,  per- 
centage of  cure,  liability  of  gangrene  of  the  extremity  or  dis- 
turbance of  circulation  and  function,  and  the  best  method 
of  treatment.  The  painstaking  study  of  Dr.  Halsted  on  the 
"Common  Iliac  Artery"1  gives  , such  information,  but  only 
for  the  one  vessel. 

There  is  one  entirely  complete  review  of  the  whole  sub- 
ject of  aneurisms — that  by  Monod  and  Vanvert.2  These 
authors  have  made  a  most  remarkable  series  of  studies  of 
blood-vessels  in  almost  every  phase  of  surgery,  giving  to 
surgeons  of  all  countries  an  inestimably  valuable  work. 

1 W.  S.  Halsted :  The  Effect  of  Ligation  of  the  Common  Iliac  Artery  on 
the  Circulation  and  Function  of  the  Lower  Extremity,  Bull,  of  the  Johns 
Hopkins  Hospital,  July,  1912. 

2  Revue  de  Chir.,  vols.  xli  and  xlii,  1910. 

6  81 


82  SURGERY  OF  THE  VASCULAR  SYSTEM 

Their  carefully  compiled  tables  of  results  and  methods,  con- 
densed and  studied  in  a  way  somewhat  different  from  the 
original,  are  here  in  grateful  acknowledgment  incorporated. 
I  shall  not  state  the  method  of  operation  done  in  each 
case  that  resulted  fatally  nor  the  other  small  factors  that 
combined  to  cause  the  unfortunate  result,  unless  there  be 
some  special  reason  for  so  doing.  The  age  of  patients  and 
the  condition  of  their  vessels  will  likewise  be  omitted  in  gen- 
eral. A  consideration  of  these  details,  important  though 
they  are,  would  thwart  the  purpose  of  this  chapter,  which,  as 
stated  above,  is  to  give  to  the  busy  surgeon  a  concrete  idea 
of  the  treatment  and  results  of  aneurisms  in  general,  to  let 
him  know  in  as  short  a  space  of  time  as  possible  and  as 
accurately  as  a  study  of  statistics  will  permit  how  he  had 
best'  handle  a  given  form  of  aneurism  and  what,  in  general, 
he  might  expect  if  he  does  follow  the  advice  given.  To  those 
who  wish  to  go  into  the  subject  at  greater  length,  I  would 
recommend  a  perusal  of  Monod  and  Vanvert 's  original 
memoirs  and  a  study  of  some  of  the  less  pretentious  mono- 
graphs on  the  subject,  references  to  which  are  appended. 

ANEURISMS  OF   THE  BASE  OF   THE   NECK.3 

Included  in  the  monograph  of  Monod  and  Vanvert  on 
aneurisms  is  a  series  of  thirty  aneurisms  which  are  arbitrarily 
classified  under  the  heading  "Aneurisms  of  the  Base  of  the 
Neck" — probably  because  they  do  not  fit  into  any  one  cate- 
gory, such  as  subclavian,  aortic,  or  innominate  aneurisms, 
but  are,  so  to  speak,  hybrid,  in  that  all  the  vessels  at  the 
root  of  the  neck  may  or  may  not  be  involved.  And  as  this  is 
the  case  it  necessarily  follows  that  all  these  vessels  have  to 
be  reckoned  with  in  the  treatment,  a  different  combination 
being  involved  in  each  instance. 

*  Monod  and  Vanvert,  Rev.  de  Chir.,  vol.  xli,  1910. 


TREATMENT  OF  ANEURISMS  83 

The  study  and  tabulation  have  been  exceedingly  difficult 
and  rather  unsatisfactory,  because,  owing  to  the  desperate 
nature  and  situation  of  many  of  the  aneurisms  and  the  con- 
sequent necessity  of  ligating  one  or  more  of  the  largest  vessels 
given  off  from  the  aorta,  but  little  can  be  expected  in  the 
way  of  a  permanent  cure.  An  improvement  and  prolongation 
of  life  in  comfort  should  in  this  series  constitute  a  successful 
result  of  the  operation.  To  regard  the  figures  in  any  other 
light  would  but  give  an  erroneous  picture  of  the  results  ob- 
tained in  a  condition  desperate  in  practically  every  aspect. 

I  have,  therefore,  studied  and  tabulated  these  cases  in  the 
following  way : 

1.  Cases  that  are  considered  complete  recoveries  by  the  respective 

authors  are  classified  as  such. 

2.  Cases  which  have  lived  a  considerable  length  of  time  but  have 

ultimately  succumbed  to  the  original  condition  are  classified 
as  improved. 

3.  Cases  which  have  died  on  the  table  or  within  a  few  days  after 

the  operation — from  whatever  cause — are  classified  as  imme- 
diate mortality. 

4.  Cases  which  have  been  observed  for  a  short  time  only  and  then 

lost  sight  of  are  classified  as  doubtful. 

All  cases  collected  between  the  years  1885  and  1909 : 

Per  cent. 

Number  of  cases 30 

Recoveries 10  =  37 

Improved 7  =  25.9 

Total v 62.9 

Immediate  mortality 10 =37 

Doubtful 1 

Eliminated  in  computation  of  percentages. 

Unimproved 2 

Eliminated  in  computation  of  percentages. 

Immediate  death  caused  by : 

Cases 

Hemorrhage 3 

Suffocation  (hemorrhage?) 1 

Cerebral  anaemia 1 

Hemiplegia 1 

Exhaustion '. 1 

Coma 1 

Not  stated . .  2 


84  SURGERY  OF  THE  VASCULAR  SYSTEM 

Cause  of  death  in  the  improved  cases : 

C  MM 

Rupture  of  aneurism  into  pleura 1 

Six  months  post-operative. 

Rupture  of  aneurism  into  pleura 1 

Two  years  post-operative. 

Not  stated 5 

In  one  case  there  was  apparently  complete  loss  of  function  in  one 
of  the  arms,  while  in  another  there  was  partial  loss.  In  no  case  did 
gangrene  occur. 

Operative  procedures: 

1.  Ligature  of  common  carotid  and  subclavian4  19,  with  following 

results: 

Deaths 7 

Recoveries 5 

Recoveries  with  weak  arms 2 

Improved 4 

Doubtful 1 

2.  Ligature  of  common  carotid  alone 1 

One  improved. 

3.  Ligature  of  common  carotid  and  subclavian  and  first  part  axil- 

lary       1 

One  recovery. 

4.  Ligature  of  common  carotid  and  first  part  axillary 4 

Three  recoveries.     One  death — coma. 

5.  Ligature  of  common  carotid  and  innominate 2 

Two  deaths. 

6.  Ligature  of  innominate  alone 3 

Three  deaths. 

In  considering  these  results,  depressing  though  they  are, 
one  cannot  help  but  be  forcibly  impressed  with  the  peculiarly 
dastardly  results  following  ligation  of  the  innominate  artery. 
Attention  to  this  fact  has  been  called  by  Savariaud,5  who 
collected  12  cases  of  ligation  of  this  vessel  between  the  years 
1884  and  1906,  no  ligations  of  choice  being  done  after  1895, 
but  two  being  necessitated  during  those  years  by  post- 

4  Part  of  the  subclavian  stated  in  about  half  of  the  cases  only,  so  I  thought 
l>est  to  leave  out  this  feature. 

5  Rev.  de  Chir.,  1906,  xxxiv,  1. 


TREATMENT  OF  ANEURISMS  85 

operative  hemorrhage  after  ligation  of  other  vessels,  one 
getting  well,  the  other  ending  fatally.  Of  the  entire  12,  one 
case  is  not  reported  completely,  four  recovered  (not  stated 
for  how  long),  and  seven  died.  It  follows  then  as  Ellsworth 
Elliott,  Jr.,6  has  said,  "That  ligation  of  the  innominate  should 
have  been  discarded  as  a  matter  of  choice  is  more  than 
justified  by  the  successful  results  achieved  by  distal  ligation 
for  aneurisms  of  the  innominate  or  the  first  part  of  the  sub- 
clavian or  both.  Of  distal  ligation  for  aneurism  of  the  first 
part  of  the  subclavian  Savariaud  has  collected  nine  cases 
without  a  death.  In  four  of  these  in  which  the  common  carotid 
was  tied  as  well,  three  were  completely  cured."7 

ANEURISMS    OF   THE    COMMON    CAROTID   ARTERY8 

All  cases  collected  between  the  years  1894  and  1908 : 

Per  cent. 

Number  of  cases 26 

Recoveries 20=76.9 

Deaths... 3  =  11.5 

Doubtful 2 

Eliminated  in  computation  of  percentages. 

Arrested / 1 

Eliminated  in  computation  of  percentages. 

Cause  of  death : 

From  hemorrhage  during  operation 1 

From  post-operative  pneumonia  (35th  day) 1 

From  hemiplegia  and  oedema  of  lungs  (3rd  day  post-operative) ....     1 

Complications : 

Pupillary  disturbances,  temporary 2 

Mental  disturbances,  temporary 2 

Facial  paralysis 1 

Hemiplegia  (one  fatal) 2 

8  Annals  of  Surgery,  July,   1912,  p.  86. 

7  In  all  the  others  there  was  considerable  improvement,  as  a  result  of 
which  Savariaud  recommends  distal  ligation  of  the  third  part  of  the  subclavian 
for  aneurisms  of  the  first  part  of  that  artery,  with  ligation  of  the  common 
carotid  as  well,  should  the  innominate  be  dilated. 

"Monod  and  Vanvert,  Rev.  de  Chir.,  vol.  xli,  1910. 


86  SURGERY  OF  THE  VASCULAR  SYSTEM 

Operative  procedures : 

Proximal  ligature 8 

Seven  recoveries  and  one  doubtful  case. 

Distal  ligature 3 

One  recovery  and  one  doubtful  and  one  arrested  case. 

Incision 2 

One  recovery  and  one  death. 

Extirpation 12 

Ten  recoveries  and  two  deaths. 

A  glance  at  these  tables  will  show  that  there  was  no 
mortality  in  the  11  cases  of  simple  ligation,  but  that  two 
deaths  occurred  in  a  like  number  of  extirpations.  This,  it 
seems  to  me,  is  about  what  one  would  expect.  It  is  usually 
more  difficult  to  extirpate  an  aneurism  than  to  do  a  simple 
ligation  no  matter  what  vessel  is  being  dealt  with,  because, 
owing  to  the  friability  of  the  aneurismal  wall  and  adhesions 
between  it  and  adjacent  structures,  especially  veins,  there  is 
always  the  prospect  of  hemorrhage  which  may  at  times  be 
uncontrollable.  Radical  extirpation,  therefore,  should  not  be 
resorted  to  where  some  other  simpler  operation  like  ligation 
or  Matas's  operation  of  endo-aneurismorrhaphy  will  answer 
the  purpose  just  as  well. 

LIGATION    OF    THE    INTERNAL    CAROTID EXTRACRAXIALLY 

Nine  cases  collected  between  the  years  1890  and  1906 — 
no  mortality. 

In  one  case  there  was  paralysis  of  the  hypoglossal  nerve 
following  injury  in  course  of  the  operation — extirpation  of 
the  sac  of  the  aneurism.  No  other  complications. 

ANEURISM  OF   THE   SUBCLAVIAN   ARTERY  9 

All  cases  collected  between  years  1898  and  1908: 

Per  cent. 

Number  of  cases 18 

Recoveries 15  =  83.3 

Deaths 1  =  5.5 

Improved 2  =  11.1 

Secondary  hemorrhage 0 

Gangrene 0 

*  Monod  and  Vanvert,  Rev.  de  Chir.,  vol.  xli,  1910. 


TREATMENT  OF  ANEURISMS  87 

Cause  of  death : 

Uncontrollable  hemorrhage  during  course  of  operation,  which 
consisted  of  ligation  of  innominate  and  common  carotid  and  incision 
of  sac. 

Complications : 

Paralysis  of  arm 1 

Disturbance  of  circulation 1 

Operative  procedures: 

Subclavian  ligated  (3  alone.) 10 

First  part - 8 

Second  part • 1 

Third  part 1 

Not  stated 1 

Innominate  and  first  part  subclavian  and  common  carotid 1 

Cure,  recurrence  having  taken  place  after  ligature  of 
innominate  alone. 

Innominate  and  first  part  subclavian 1 

One  cure. 

Innominate  and  common  carotid  and  incision  of  sac 1 

One  death. 

Innominate  ligated  distally  alone 1 

One  cure. 
First  part  subclavian  and  inferior  thyroid  and  vertebral  and  third 

part  axillary 1 

Cure,  recurrence  having  taken  place  after  ligation  of 
first  part  subclavian. 

First  part  subclavian  and  common  carotid 1 

One  cure. 

Third  part  subclavian  and  common  carotid 1 

One  cure. 

First  part  subclavian  and  first  part  axillary 1 

Paralysis  of  arm. 

First  part  subclavian  and  axillary 1 

Circulatory  disturbance. 

Ligation  of  carotid 3 

One  death  and  two  cures. 

Extirpation 4 

Four  cures. 

We  thus  see  that  in  10  out  of  the  18  cases  it  was  neces- 
sary to  ligate  two  or  more  vessels  in  order  to  effect  a  cure, 
and  that  in  this  series  all  the  mishaps  occurred.  This  multiple 
ligation  was  done  in  several  cases  at  a  second  operation,  a 


88  SURGERY  OF  THE  VASCULAR  SYSTEM 

recurrence  having  taken  place  after  ligation  of  a  single  vessel. 
Worthy  of  note,  too,  is  the  fact  that,  in  both  of  the  cases  of 
•trouble  in  the  arm,  ligation  of  the  axillary  artery  was  part 
of  the  operative  procedure,  thus  bearing  out  the  well-known 
observation  that  "the  further  away  from  the  heart  at  which 
the  main  arterial  trunk  is  ligated,  the  greater  the  danger  of 
functional  disturbance  and  gangrene." 

ANEURISMS  OF  THE  AXILLARY  ARTERY  10 

All  cases  collected  between  the  years  1895  and  1909 : 

Number  of  cases  " 24 

Per  cent. 

Recoveries 23  =95.8 

Deaths 1  =  4.2 

Gangrene 0 

Functional  impairment 5  =  20.8 

Post-operative  hemorrhage 2  =  8.4 

Operative  procedures: 

Extirpations 12 14 

Functional  impairment 3 

Death 1 

In  this  case  after  extirpation  a  venous  transplant  was  sutured  be- 
tween the  ends  of  the  artery,  patient  dying  of  delirium  tremens 
several  days  later.13 

Ligation  of  subclavian 9 

Functional  impairment 2 

Post-operative  hemorrhage 2 

One  case  resulted  from  infection. 

The  striking  feature  of  this  series  of  cases  is  the  number 
of  functional  impairments,  which  after  all  should  be.  the 
criterion  of  success  or  failure  in  aneurisms  of  the  extremities, 
there  being  little  or  no  occasion  for  mortality.  It  would  seem 

"Monod  and  Vanvert,  Rev.  de  Chir.,  vol.  xli,  1910. 

11  Monod  and  Vanvert  cite  one  other  case  which  I  threw  out  because  the 
aneurismal  sac  was  removed  when  an  exarticulation  of  the  shoulder-joint  was 
done. 

a  During  the  course  of  these  extirpations  the  vein  was  resected  three  times 
without  apparent  complications. 

"Lexer,  Arch.  f.  klin.  Chir.,  1907,  Ixxxiii,  458. 


TREATMENT  OF  ANEURISMS  89 

as  if  Matas's  operation  offers  better  results  in  these  aneurisms 
than  either  extirpation  or  ligation. 

ANEURISMS   OF    THE   BRACHIAL   ARTERY  14 

All  cases  collected  between  the  years  1895  and  1909 : 

Number  of  cases 22 

Recoveries 22 

Gangrene 0 

Functional  disturbances 2 

Operative  procedures: 

Extirpation 18 

Vein  was  resected  once  without  complications. 

Functional  disturbances 1 

Proximal  ligature 2 

Functional  disturbance 1 

Incision 2 

In  several  of  these  cases  the  radial  pulse  reappeared  after 
a  number  of  days '  absence — once  after  46  days.  Its  presence 
or  absence  cannot,  therefore,  be  of  any  great  prognostic  value. 
In  both  of  the  noted  cases  of  functional  disturbance  it  was 
present  almost  immediately  after  operation,  although  in  one 
it  was  barely  perceptible.  In  one  of  the  cured  cases  it  was 
never  present  after  operation. 

LIGATION   OF   THE   COMMON   ILIAC   ARTERY15 

All  cases  collected  between  years  1880  and  1912: 

Per  cent. 

Number  of  cases 30 

Recoveries : 16  =53.3 

Deaths 14  =46.6 

Gangrene 12  =40 

In  most  all  of  these  cases  there  were  complications  (see  page  90) 
other  than  the  simple  ligation  of  the  vessel,  which  contributed 
quite  materially  to  the  bad  result.  So  marked  were  these  com- 
plications that  Dr.  Halsted  came  to  the  conclusion,  after  careful 
consideration  of  each  individual  case,  "that  the  uncomplicated 
ligation  of  the  common  iliac  artery  is  not  likely  to  be  followed  by 
gangrene,  the  percentage  being  from  3.3  to  6.6.  instead  of  33.3 

14  Monod  and  Vanvert,  Rev.  de  Chir.,  vol.  xli,  1910. 

15  W.  S.  Halsted,  Bull.  Johns  Hopkins  Hospital,  July,  1912. 


90  SURGERY  OF  THE  VASCULAR  SYSTEM 

(as  given  by  Mataa  in  vol.  v  of  Keen's  Surgery);  and  that  the 
mortality  .  .  .  is  at  most  10  per  cent,  and  probably  not  more  than 
6.6  per  cent.,  or  it  may  even  be  as  low  as  3.3  per  cent." 

Gangrene: 

In  two  of  the  12  cases  of  gangrene,  the  condition  was  present 
before  operation  and  in  three  other  cases  it  was  very  slight. 

Recoveries: 

In  five  out  of  16  recoveries  there  was  some  functional  impair- 
ment, usually  slight. 

Cause  of  death: 

Difficult  and  prolonged  operation  and  hemorrhage 2 

Infection 2 

Both  cases  were  done  in  the  pre-antiseptic  era,  1871-79,  but 
were  not  reported  till  1880  and  1885  respectively. 

Nephritis 1 

Possibly  due  to  increased  blood-pressure. 

Pre-operative  gangrene  and  hemorrhage 1 

Peritonitis,  thrombosis,  and  gangrene 1 

Hemorrhage  and  gangrene 1 

Hemorrhage 1 

Ligation  of  aorta  37  days  after  ligation  of  common  iliac. 

Pre-operative  gangrene  of  scrotum,  hemorrhage  and  diarrhoea .  1 

Miliary  tuberculosis , 1 

Arteriosclerosis  and  gangrene 1 

Hemorrhage 1 

Not  stated 1 

I  have  thus  tabulated  the  various  causes  of  death  in  each 
case  in  order  to  show  how  easily  one  could  be  misled  if  he 
merely  consulted  the  table  and  its  accompanying  percentages, 
and  I  went  into  the  details  of  the  gangrene  cases  for  a  similar 
purpose.  The  percentage  of  gangrene  is  by  no  means  40  nor 
is  the  mortality  anywhere  near  46.6.  In  nearly  every  case 
there  were  contributing  causes  other  than  simple  ligation 
of  the  common  iliac  artery.  For  example,  in  two  cases  the 
gangrene  was  present  before  operation  and  in  the  list  of 
deaths  there  were  two  fatalities,  which,  done  in  pre-antiseptic 
times  but  not  reported  till  well  in  the  antiseptic  era,  died  of 
infection.  Another  case  died  of  miliary  tuberculosis,  several 
died  of  hemorrhage,  and  so  on.  Dr.  Halsted  has  given  a  most 
valuable  contribution  to  the  study  of  aneurisms  and  I  recom- 


TREATMENT  OF  ANEURISMS  91 

mend  a  perusal  of  the  original  article  to  those  who  are  in- 
terested in  the  subject — especially  those  who  have  a  case  of 
aneurism  of  the  common  iliac  artery  to  handle. 

ANEURISMS    OF    THE    EXTERNAL.   ILIAC    ARTERY  16 

All  cases  collected  between  the  years  1895  and  1909 : 

Per  cent. 

Number  of  cases , 24 

Recoveries 15  =62.5 

Deaths 9  =37.5 

Gangrene 4  =  16.6 

Functional  impairment 2  =  8.3 

Post-operative  hemorrhage 0 

Operative  procedures: 

Ligature  of  aorta  (alone) 1 

One  death. 

Ligature  of  common  iliac  (alone) 5 

Two  deaths,  one  of  which  had  gangrene.    Three  recoveries,  one 
of  which  had  impairment  of  function. 

Ligature  of  external  iliac  (alone) 7 

One  death,  five  recoveries  and  one  case  lost  sight  of. 

Compression 1 

One  recovery. 

Extirpation 4 

Two  deaths,  one  of  which  died  of  embolus  after  end-to-end  suture 
of  external  iliac.    Two  recoveries. 

Ligature  of  common  iliac  and  femoral 1 

One  recovery  after  gangrene  and  amputation. 

Ligature  of  external  iliac  and  femoral  .  . . ! 4 

Two  deaths,  one  of  which  had  gangrene.    One  functional 

impairment.     One  recovery. 
Ligature  of  external  iliac  and  aorta,  necessitated  by  post-operative 

hemorrhage  after  ligature  of  external  iliac 1 

One  death. 

It  has  been  generally  understood  that  gangrene  of  the 
leg  is  a  common  occurrence  following  ligation  of  the  external 
iliac  artery  and  the  above  figures  substantiate  this  belief,  at 
least  to  a  certain  degree.  The  exact  reason  for  this  mishap 
has  never  been  'satisfactorily  explained.  Until  the  question 

"Monod  and  Vanvert,  Rev.  de  Chir.,  vol.  xli,  1910. 


92  SURGERY  OF  THE  VASCULAR  SYSTEM 

has  been  definitely  settled  it  would  seein  advisable  to  use 
Ilalsted's  method  of  gradual  occlusion  of  vessels  in  handling 
aneurisms  of  this  artery.  Matas's  procedure,  too,  might  be 
productive  of  better  results  here. 

ANEURISMS  OF    THE   FEMORAL,  ARTERY17 

All  cases  collected  between  the  years  1895  and  1909: 18 

Per  cent. 

Number  of  cases 66 

Recoveries 58  =  92 

Deaths 5  =  7.9 

Gangrene 4  =  6.3 

Functional  disturbance 1 

Lost  sight  of 3 

Eliminated  in  figuring  percentages. 

Operative  procedures : 

Ligature  external  iliac 19 12 

One  death.     One  case  lost  sight  of.     Ten  recoveries. 

Ligature  external  iliac  and  femoral19 2 

Two  recoveries. 

Ligature  femoral  artery 5 

Four  recoveries.     One  gangrene  and  amputation. 

Ligature  femoral  and  popliteal  arteries 1 

One  death  (cardiac). 

Extirpation 41 

Thirty-two  recoveries.  Three  deaths:  1  post-operative  hemor- 
rhage; 1  oedema  of  lungs;  1  erysipelas;  1  functional  impairment; 
1  gangrene  and  amputation;  2  superficial  gangrene;  2  cases  lost 
sight  of. 

Incision 4 

Four  recoveries. 

Compression 1 

One  recovery. 

"Monod  and  Vanvert,  Rev.  de  Chir.,  vol.  xlii,  1910. 

"  Monod  and  Vanvert  divided  these  cases  into  two  groups,  (a)  those  of  the 
inguinal  femoral  and  (6)  those  of  the  superficial  femoral.  We  do  not  make  this 
distinction  in  this  country  so  far  as  I  am  aware,  so  I  have  considered  the  cases 
altogether,  making  one  group. 

"These  ligations  of  the  external  iliac  really  amounted  to  a  rather  high 
femoral  ligature  in  that  most  of  them  were  not  far  above  Poupart's  ligament. 


TREATMENT  OF  ANEURISMS  93 

The  results  of  this  series  of  cases  are  quite  favorable,  but 
I  believe  even  better  results  will  be  secured  if  a  more  general 
use  of  Matas's  endo-aneurismorrhaphy  is  made  in  aneurisms 
of  this  vessel.  In  the  three  cases  of  gangrene  which  followed 
extirpation,  the  vein,  being  quite  adherent  to  the  sac,  was 
either  ligated  or  resected  during  removal  of  the  sac.  This 
should  teach  us,  I  think,  that  every  effort  should  be  made  to 
preserve  the  vein  intact,  no  matter  what  operative  procedure 
is  adopted.  In  case  of  its  unavoidable  injury  it  should  be 
repaired.  If  its  resection  is  required  a  venous  transplant 
had  best  be  done  immediately.  It  must  be  admitted,  however, 
that  the  vein  was  ligated  in  several  other  instances  in  which 
there  was  no  disturbance,  but  this  does  not  alter  the  facts 
as  above  stated.  Matas's  operation  probably  offers  the  best 
solution.  The  ideal  operation  of  complete  excision  of  the 
aneurism  followed  by  arterial  anastomosis  will  also  be  of 
service  in  selected  cases. 

ANEURISMS  OF   THE   POPLITEAL  ARTERY  20 

All  cases  collected  between  the  years  1895  and  1909 : 

Per  cent. 

Number  of  cases 151 

Recoveries 147  =97.3 

Deaths21 4  =  2.6 

Gangrene22 22  =  14.5 

Superficial  gangrene 2 

Functional  disturbance. . .  6=  3.9 


20Monod  and  Van  vert,  Rev.  de  Chir.,  vol.  xlii,  1910. 

21  One  of  the  deaths  resulted  from  septicaemia. 

~  In  two  or  three  instances  the  gangrene  had  started  before  operation  on 
the  aneurism;  it  continued  to  progress  after  operation. 

Of  the  22  cases  of  gangrene,  amputation  of  the  leg  or  foot  was  necessitated 
in  18  cases,  amputation  of  the  toes  in  four  cases.  One  of  these  cases  was  a 
trophic  disturbance  and  not  a  true  gangrene,  but  inasmuch  as  amputation  was 
required  it  is  classified  as  a  case  of  gangrene. 


25  per  cont.25 
Per  cent. 


94  SURGERY  OF  THE  VASCULAR  SYSTEM 

Operative  procedures: 

Per  cent 

Extirpations  n 104 

Recoveries 102  =98 

Deaths 2  =   1.9 

Gangrene 13  =  12..', 

Superficial  gangrene 2 

Functional  disturbance 4  =  3.8 

Vein  was  ligated  or  resected  at  time  of  extir- 
pation      24     Per  cent. 

Gangrene 3  =  12.5 

Superficial  gangrene 1 

Circulatory  disturbance 1 

(Edema  of  the  leg24 1 

Ligature  of  femoral  artery 32 

Recoveries 31  =96.8 

Death 1  =  3.1 

Gangrene 8  =  25 

Functional  disturbance 1 

Post-operative  hemorrhage M 2=  6.2 

Ligature  of  popliteal  artery 2 

Recoveries 1 

Death 1 

Gangrene  of  great  toe  in  this  case. 

"In  one  of  these  cases  after  excision  of  the  aneurismal  sac,  the  vein  \\;i* 
resected  and  the  resected  part  transplanted  successfully  between  the  two  ends  of 
the  artery.  (J.  Goyanes,  El  Siglo  med.,  1906,  liii,  p.  561.) 

In  another  case  after  excision  of  the  sac,  the  arterial  ends  were  sutured, 
the  knee  being  acutely  flexed  so  as  to  approximate  the  ends.  They  were  4  cm. 
apart.  Case  successful.  (Enderlen,  Deutsch.  med.  Woch.,  1908,  xxxiv,  p.  l.">si., 

**  This  case  was  cured  one  year  after  operation  by  transplanting  a  segment 
of  vein  l>etween  the  two  ends  of  the  resected  vein.  (E.  Doyen,  22d  Cong.  fr.  de 
Chir.,  1909,  178.) 

28  This  percentage  is  given  to  show  that  in  25  per  cent,  of  those  cases  in 
which  the  vein  was  ligated  or  resected  at  the  time  of  operation  some  circulatory 
disturbance  occurred,  thus,  I  think,  proving  conclusively  that  a  serious  attempt 
ought  always  be  made  to  save  the  vein.  It  is  more  than  likely,  too,  that  some 
circulatory  disturbance  occurred  in  cases  other  than  those  in  which  it  was  noted. 

"One  of  these  cases  was  saved  by  ligating  the  femoral  higher  up  in  its 
course.  In  the  other  this  did  not  stop  the  hemorrhage,  so  the  external  iliac  w;i< 
ligated.  The  foot  then  became  gangrenous  and  had  to  be  amputated.  These  are 
the  only  two  cases  of  post-operative  hemorrhage  reported  in  the  entire  series  of 
151  cases.  One  of  them  was  clearly  the  result  of  arteriosclerosis.  Neither  case 
was  infected. 


TREATMENT  OF  ANEURISMS  95 

Per  cent. 

Compression 27 9 

Recoveries 9 

One  of  which  was  merely  improved. 

Incision 2 

Recoveries 2 

In  one  of  which  there  was  functional  disturbance. 

Forced  flexion  (compression) 2 

Recoveries 2 

There  can  be  little  question,  I  believe,  that  a  painstaking 
preliminary  study  of  the  collateral  circulation  of  the  limb  in 
cases  of  popliteal  aneurism  will  avert  many  cases  of  gangrene 
that  might  otherwise  occur.  It  would  seem,  too,  that  Matas's 
endo-aneurismorrhaphy  is  peculiarly  well  adapted  to  the 
treatment  of  these  aneurisms,  and,  where  conditions  warrant, 
excision  of  the  aneurism  followed  by  a  vascular  transplant 
and  suture  might  well  be  practised. 

ARTERIO VENOUS  ANEURISMS  OF  THE  SUBCLAVIAN   VESSELS  M 

CASE  I. — Done  in  1845: 

Double  ligature  of  third  part  of  subclavian  artery. 
Infection. 

Secondary  hemorrhage. 
Death. 

CASE  II.— Done  in  1906: 

Attempted  excision  of  sac. 

Hemorrhage  from  jugular  vein. 
Death  two  hours  after  operation. 

CASE  III. — Done  in  1906: 

Ligation  of  innominate  artery. 
Recurrence. 
Excision  of  sac. 
Recovery. 
Improvement  of  palsy  of  arm  present  before  operation. 

•7  Compression  was  tried  in  a  number  of  cases  and  failed,  some  other  opera- 
tion like  ligation  or  extirpation  being  then  instituted. 
KMonod  and  Vanvert,  Rev.  de  Chir.,  vol.  xlii,  1910. 


96  SURGERY  OF  THE  VASCULAR  SYSTEM 

ABTEKIOVENOUS  ANEURISMS  OF  THE  VESSELS  OF  THE   NECK  '-"' 

All  cases  collected  between  the  years  1889  and  1910 : 

I\T  cent. 
Number  of  cases 11 

Cured 9=81.8 

Improved 2  =  18.1 

Deaths 0 

Operative  procedures : 

Extirpation 4 

Proximal  ligature  of  carotid 2 

These  were  the  cases  in  which  improvement  occurred. 

Distal  ligature  of  carotid 2 

Quadruple  ligature 3 

There  were  apparently  no  complications  and  no  post- 
operative disturbances  that  were  not  present  before  operation, 
and  most  of  these  disappeared,  only  a  few  minor  ailments 
remaining. 

There  were  one  case  of  arteriovenous  aneurism  of  the 
internal  carotid  (extracranial)  and  three  cases  of  the  external 
carotid,  all  of  which  were  cured  without  difficulty  by  opera- 
tion, the  first  by  ligation  of  the  external  carotid  at  its  origin, 
the  common  carotid  and  the  jugular  vein  (case  of  W.  W. 
Keen,  Times  and  Register,  Philadelphia,  1894,  xxvii,  151). 
The  last  three  were  cured  by  extirpation. 

ARTERIOVENOUS  ANEURISMS  OF   THE   AXILLARY   VESSELS29 

All  cases  collected  between  the  years  1885  and  1908 : 

Number  of  cases 10 

Cures 7 

Improved 2 

Circulatory  disturbance 1 

Deaths 0 

"Monod  and  Vanvert,  Rev.  de  Chir.,  vol.  xlii,  1910. 


TREATMENT  OF  ANEURISMS  97 

Operative  procedures : 

Extirpation 6 

Resection  of  vein  in  one  case  without  complication.    Circulatory 
disturbance,  one. 

Compression 2 

Both  cases  improved. 

Ligature 1 

Separation  of  vein  and  artery  followed  by  suture  of  holes  in  each ...     1 

Successful. 


ARTERIOVENOUS  ANEURISMS   OF   THE   BRACHIAL   VESSELS  30 

All  cases  collected  between  the  years  1891  and  1909 : 

Number  of  cases 14 

Cures 12 

Functional  impairment 2 

Deaths 0 

Operative  procedures : 

Extirpation 11 

Resection  of  the  vein  once  without  complications.    Functional 
impairment,  two. 

Ligature 2 

Resection  of  vein  once  without  complications. 
Lateral  suture  of  artery 1 

ARTERIOVENOUS   ANEURISMS   OF    THE    FEMORAL   VESSELS  30 

All  cases  collected  between  the  years  1890  and  1909: 

Number  of  cases 58 

Recoveries 54 

Deaths 4 

One  from  septicaemia  after  ligature  of  common  iliac.  One  from 
hemorrhage  during  operation.  Two  followed  gangrene  and  am- 
putation after  ligature  of  external  iliac. 

Gangrene . 10 

(a)  In  eight  cases  amputation  was  necessary,  two  of  these 
patients  dying.  External  iliac  was  ligated  four  times  with  two 
deaths.  Femoral  artery  was  ligated  four  times,  twice  proximal 
and  distal — twice  proximal. 

"Monod  and  Vanvert,  Rev.  de  Chir.,  vol.  xlii,  1910. 


98  SURGERY  OF  THE  VASCULAR  SYSTEM 

(6)  In  two  of  these  cases  the  gangrene  was  only  superficial  and 
followed  ligature  of  the  external  iliac  once  and  extirpation  once. 

Functional  disturbance 2 

In  both  cases  the  leg  was  a  little  weak  and  followed  ligature  of 
the  external  iliac  once  and  extirpation  once. 

Operative  procedures: 

Extirpation 40 

Recoveries :;~> 

Deaths 1 

Slight  superficial  gangrene _' 

In  one  of  these  cases  the  external  iliac  was  ligated  before  the 
extirpation. 

Slight  weakness  of  leg 2 

In  one  of  these  cases  the  external  iliac  was  ligated  before  the 
extirpation. 

Ligature  of  femoral  artery  proximal  and  distal  or  proximal 9 

Recoveries 5 

Gangrene 4 

Proximal  and  distal  ligation  twice;  proximal  alone  twice. 

Ligature  of  external  iliac  artery 7 

Recoveries •"> 

Deaths 2 

Gangrene 4 

Weakness  of  leg 1 

Ligature  of  common  iliac 1 

Death 1 

From  septicaemia. 

Incision 1 

Recovery. 

A  study  of  these  tables  reveals  the  fact  that  arteriovenous 
aneurisms  of  the  femoral  vessels  is  a  more  serious  affection 
than  aneurism  of  the  artery  alone.  It  also  shows  pretty 
clearly  that  the  external  iliac  artery  had  best  be  given  a  wide 
berth.  But  the  most  surprising  thing  of  all  is  the  splendid 
results  following  simple  extirpation  and  the  comparatively 
poor  results  following  ligation  of  the  femoral  artery  without 
extirpation.  Perhaps  some  future  study  will  explain  this 
apparent  contradiction.  In  excising  an  aneurism  of  this  char- 
acter, the  vein  must  necessarily  be  included,  and  this  means 
ligation  of  both  vessels,  a  procedure  that  ought  to  be  more 


TREATMENT  OF  ANEURISMS  99 

dangerous  to  life  and  limb  than  simple  ligation  and  more 
productive  of  gangrene  and  functional  disturbance.  I  have 
gone  over  the  cases  carefully  and  offer  the  figures  for  what 
they  are  worth,  though  I  must  confess  they  do  not  "look 
right. ' ' 

ARTERIOVENOUS  ANEURISMS  OF   THE  POPLITEAL  VESSELS  31 

All  cases  collected  between  the  years  1891  and  1908 : 

Number  of  cases 35 

Recoveries 34 

Deaths 1 

Followed  extirpation. 

Gangrene 6 

In  two  cases  amputation  was  necessary,  extirpation  being  done 
in  one  case,  ligature  of  femoral  artery  and  vein  in  other. 

In  four  cases  gangrene  was  only  superficial,  extirpation  being 
done  in  three  cases,  quadruple  ligature  in  one  case. 

Functional  disturbance 6 

In  one  case  leg  was  oedematous.     In  one  case  there  was  pain 

and  claudi cation. 

In  four  cases  there  were  muscular  contractures,  limited  motion, 

pain  and  paralysis  of  foot.    In  all  four  cases  extirpation  of  the  sac 

was  done  and  in  each  instance  the  leg  was  practically  useless. 

Operative  procedures : 

Extirpations32 28 

Cures.  .  .  i 17 

Gangrene 4 

Functional  disturbance 6 

Deaths 1 

Quadruple  ligatures 4 

In  one  case  gangrene  of  toes.    In  three  cases  recovery. 

Ligature  of  femoral  artery  and  vein 3 

Recovery  in  two  cases.     Gangrene  and  amputation  in  one  case. 

Here  we  have  what  I  expected  to  find  in  the  study  of 
arteriovenous  aneurisms  of  the  femoral  vessels — disastrous 
results  following  extirpation  of  the  aneurismal  sac.  The 
figures  speak  for  themselves  and  discussion  is  all  but  super- 

31  Monod  and  Vanvert,  Rev.  de  Chir.,  vol.  xlii,  1910. 

32  In  two  cases  of  extirpation  an  end-to-end  suture  of  the  artery  was  done 
with  perfect  recovery  in  each  case. 


100         SURGERY  OF  THE  VASCULAR  SYSTEM 

fluous.  I  cannot  refrain,  however,  from  railing  attention  to 
the  two  successful  end-to-end  sutures  that  were  done  after 
the  aneurism  had  been  extirpated.  The  one  was  done  by 
Lexer,33  the  other  by  Stich.34 

This,  of  course,  is  the  ideal  method  of  dealing  with  these 
and  a  great  many  other  aneurisms,  but  the  general  run  of 
surgeons  is  not  ready  yet  to  do  a  successful  arterial  suture. 
And  inasmuch  as  Matas's  operation  gives  such  splendid  and 
uniform  results,  perhaps  it  is  just  as  well  that  such  is  the 
case. 


Arch.  f.  kl.  Chir.,  1907,  Ixxxiii,  p.  438. 
Deutsoh.  Zeit.  f.  Chir.,  1908,  xcv,  p.  577. 


INDEX 


Adventitia,  importance  cf,  1 

treatment  of,  for  end-to-end  suture, 

28 
Aluminum  bands,   Halsted's  method  of 

rolling,  79 
Anastomosis,  art erio venous.   See  Arterio- 

venous  anastomosis 
lateral,  37 
saphenofemoral.     See  also   Lateral 

anastomosis,  62 

technic   of,    with   Bernheim's   two- 
pieced  cannula,  18 

Aneurismal  sac,  drainage  of  infected,  71 
of  ruptured,  71 
of  uninfected,  71 
of  unruptured,  71 
obliteration  of,  71,  72 
Aneurisms,    arteriovenous,   statistics   of 

treatment  of,  95 
of  axillary  vessels,  96 
of  brachial  vessels,  97 
of  femoral  vessels,  97 
of  popliteal  vessels,  99 
of  subclavian  vessels,  95 
of  vessels  of  neck,  96 
endo-aneurismorrhaphy  (Matas)  for, 

68,  69 

extirpation  of,  68,  69 
Halsted's  method  of  gradual  occlu- 
sion of  blood-vessels  for,  69,  78 
Matas  operation  for,  68,  69 
methods  of  treatment,  68,  69,  73,  78 
arterial  suture,  68 
endo-aneurismorrhaphy,  68,  69 
excision,  68 
extirpation,  68,  69 
Halsted's  aluminum  bands,  68, 

78 

ligation,  68 
wiring,  68,  73 

Moore-Corradi   method   of   wiring, 
technic  of,  73 


Aneurisms,  occlusion  of  blood-vessels  in 

treatment  of,  78 
of  abdominal  aorta,  68 

wiring  of,  75 
of  arch  of  aorta,  68 
of  popliteal  artery,  68 
of  vessels  at  root  of  neck,  68 
operations  for,  68,  69,  73,  78 
statistics  of  treatment  of,  81-100 
of  axillary  artery,  88 
of  brachial  artery,  89 
of  common  carotid  artery,  85 
of  external  iliac  artery,  91 
of  femoral  artery,  92 
of  popliteal  artery,  93 
of  subclavian  artery,  86 
of  vessels  of  base  of  neck,  82 
wiring  of,  69,  73 
benefits  from,  76 
complications  from,  75,  76 
indications  for,  73 
Moore-Corradi  method  of,  73 
post-operative  treatment,  76 
preliminary  treatment,  77 
prognosis,  77 
statistics  of,  77 
Arteriovenous    anastomosis.      See    also 

Reversal  of  circulation,  53 
employment  of,  53 
methods  of,  53 
statistics  of,  54 
Artery,  ligation  of,  69 

Ball-tipped  forceps,  2 
Bernheim's   three-pronged   modification 
of  Crile's  transfusion  cannula,  13 
transfusion  cannula,  15 

value  of,  16 

Blood  flow,  amount  of,  during  transfu- 
sion, 24 

duration  of,  in  transfusion,  25 
tests  during  transfusion,  22 

101 


102 


INDEX 


Blood-pressure  during  transfusion,  21,  -'2 
Blood-vessel  clamps,  4 
Blood-vessels,  exposure  of,  2 

for  end-to-end  suture,  28 
handling  of,  2 

of  severed,  3 

occlusion  of,  in  treatment  of  aneu- 
risms, 78 
structure  of,  1 
surgery  of,  hjcmostasis  during,  3 

instruments  for,  2 

liquid  vaseline  in,  3 

needles  for,  5 

preparation  of  hands  for,  6 

rubber  gloves  in,  6 

salt  solution  in,  3 

technic  of,  1 

Cardiolysis,  64,  66 

indications  for,  66 

Carrel's  method  of  arteriovenous  anasto- 
mosis, 53 
Circulation,  reversal  of.    See  Reversal  of 

circulation 
Clamps,  bull-dog,  4 
Crile,  4 
rubber  shod,  4 
Crile's  transfusion  cannula,  10 

Bernheim's  modification  of,  13 
technic  of  use  of,  10 

Elsberg's  transfusion  cannula,  13 
Endo-aneurismorrhaphy  (Matas),  68,  69 

advantages  of,  73 

methods  of,  69,  70 

obliterative,  70 
•  reconstructive,  70 

restorative,  70,  72 
methods  of,  72 

statistics  of,  73 
End-to-end  suture,  28 

completed  line  of,  33 

exposure  of  blood-vessels  for,  28 

leakage  in,  33 

massage  of  blood-vessels  after,  34 

starting  blood  flow  after,  35 

treatment  of  adventitia  in,  28 
Exposure  of  blood-vessels  for  end-to-end 
suture,  28 


Forceps,  ball-tipped,  2 

Glass  tubes,  paraffined,  for  transfusion. 
16 

Hiemostasis  during  blood-vessel   opera- 
tions, 3 

Ha-molysis  following  transfusion,  26 
Halsted's  metal  bands  for  occlusion  of 

blood-vessels,  78 
metal  band  roller,  79 
method  of  occlusion  of  blood-v 

69,  78 

degree  of  occlusion,  80 
technic  of,  79 
method  of  rolling  aluminum  bands. 

79 
Handling  of  blood-vessels,  2 

of  severed  blood-vessels,  3 
Hands,  preparation  of,  for  blood-vessel 

surgery,  6 

Heart,  exposure  of,  64 
injury  to,  64 
suture  of,  64 
surgery  of,  64 
statistics  of,  65 
transfusion  in,  65 
use  of  salt  solution,  65 
Historical  note,  vii 

Injuries  to  the  heart,  64 
Instruments,  blunt,  2 
Intima,  role  of,  1 

Lateral  anastomosis,  37 

development  of  thrombi,  45 

employment  of,  37 

leakage  after,  41 

methods  of,  37 

proximal  ligation  of  vein  follow- 
ing, 44 

suture  of,  40 

technic  of,  according  to  method  of 
Bernheim  and  Stone,  39 

transverse  incision  of  vessels  for, 
39 

value  of,  45 
Liquid  vaseline,  effect  of,  on  tissues,  3 

in  blood-vessel  surgery,  3 


INDEX 


103 


Ligation  of  common  iliac  artery,  statis- 
tics of,  89 

of   internal   carotid    extracranially, 
statistics  of,  86 

Matas  operation,  69 

(See  also  Endo-aneurismorrhaphy) 

Media,  role  of,  1 

Moore-Corradi  method  of  wiring  aneu- 
risms, 73 

Needles,  5 

insulation  of,  for  wiring  aneurisms,  74 
preparation  of,  5 

Over-and-over  stitch,  30 

Pericardiotomy,  64,  66 
Pericardium,  drainage  of,  67 
exposure  of,  66 

dangers  in,  66 

salt  solution  in,  66 

Physical  examination  for  transfusion,  26 
Pulse  during  transfusion,  21,  22 

Reversal  of  circulation,  53 
case  of,  57 

conditions  warranting,  56 
contra-indications  for,  55 
controversies  concerning,  54 
employment  of,  53 
formation  of  thrombus,  55 
in  four  extremities,  57 
.     methods  of,  53 
pain  after,  59 
possibility  of,  55 

precautions  to  be  observed  in,  59 
statistics  of,  54 
vein  valves  in,  54,  57 

Salt  solution,  effect  on  tissues,  3,  4 
in  blood-vessel  surgery,  3 
in  exposure  of  pericardium,  66 
in  heart  surgery,  65 
Saphenofemoral  anastomosis,  62 
Schede's  operation  for  varicose  veins,  61 
Statistics  of  endo-aneurismorrhaphy,  73 


Statistics  of  heart  surgery,  65 

of  reversal  of  circulation, 

of  treatment  of  aneurisms,  81-100 

of  wiring  of  aneurisms,  77 
Stay  sutures,  30 
Stitch,  over-and-over,  30 
Subcutaneous  method  of  removing  vari- 
cose veins,  62 
Suture,  completed  line  of  end-to-end,  33 

end-to-end,  28 

material,  4 

stay,  30 

Tissues,  effect  of  liquid  vaseline  on,  3 

of  salt  solution  on,  3,  4 
Transfusion,  8 

amount  of  blood  flow  during,  24 

anaesthetic  in,  18 

blood-pressure  during,  21,  22 

blood  tests  during,  22 

cannula,  Bernheim's  modification  of 

Crile's,  13 
two-pieced,  15 

technic  of  use  of,  16 
value  of,  16 
Crile's,  10 

technic  of  use  of,  10 
Elsberg's,  13 

method  of  using,  13 
conditions  warranting,  8 
direct,  8 

dissection  of  radial  artery  for,  18 
duration  of  blood  flow  in,  25 
haemolysis  following,  26 
in  anaemia,  9 
in  gastric  ulcers,  8 
in  haemophilia,  9 
in  hemorrhage,  8 
in  heart  surgery,  65 
in  illuminating  gas  poisoning,  9 
indirect,  8 
in  infants,  9 
in  leukaemia,  9 
in  melaena'neonatorum,  9 
in  pellagra,  9 
in  ruptured  extra-uterine  pregnancy, 

8 
in  shock,  9 


104 


INDEX 


Transfusion,  instruments  for,  10,  13,  15 
in  1 1 ixn'ii ii;i>.  9 

of  pregnancy,  9 
in  typhoid  ulcers,  8 
methods  of,  8 

physical  examination  for,  26 
pulse  during,  21,  22 
technic  of,  10,  13,  16 
welfare  of  donor  during,  25 
Transplantation  of  blood-vessels,  46 
arterial,  46,  48 
cold  storage  tissue  for,  46 
hemorrhage  following,  51 
sutures  used  in,  51 
technic  of,  49 
venous,  46,  48 

Trendelenburg's  operation  for  varicose 
veins,  61 


Triangles,  formation  of,  30 

Valves  of  veins,  in  reversal  of  the  circula- 
tion, 54,  57 
Varicose  veins,  61 

methods  of  resecting,  62 
saphenofemoral  anastomosis    for, 

62 

Schede's  operation  for,  61 
subcutaneous  method  of  removing, 

62 

treatment  of,  61,  63 
Trendelenburg's  operation  for,  01 
Veins,  resection  of,  62 
complete,  62 
partial,  62 
valves  of,  54,  57 

Wiring  of  aneurisms,  73 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DUE  on  the  last  date  stamped  below. 


MAR  8      1981 

FEB  P. 


JUU    B68 


\ 


V 


MAR*P 
MAR  14RHTD 


BIOMED   AUG2519e3 


Form  L9-10m-3,'48(A7920)444 


BIOMEO  LiB. 

AUG25RECT] 
BtOMEO  MftV  1 6  f85 


1579 


UB. 


THE  LIBRARY 


168  °urgery  of  the 
84  57s Vascular  Syste 
1913 


Biomediod 
Lihrarr 


m 

168 

B457s 

1913 

•Medical 
llbraiy 


• 


